t'R&FFSSOR  OF  GYNECOLOGY, 
Sbieago  IBedieal  (Sollege. 


THE  UNIVERSITY 
OF  ILLINOIS 
LIBRARY 


From  the  collection  of 
Julius  Doerner,  Chicago 
Purchased,  1918. 


Digitized  by  the  Internet  Archive 
in  2017  with  funding  from 

University  of  Illinois  Urbana-Champaign  Alternates 


https://archive.org/details/displacementsofuOOdudl 


DISPLACEMENTS 


o p 

THE  UTERUS. 


BY 

B.  C.  DUDLEY,  A.B.,  M.D., 

PROFESSOR  OF  GYNECOLOGY  IN  THE  CHICAGO  MEDICAL  COLLEGE. 


REPRINTED  FROM  PEPPER’S  SYSTEM  OF  MEDICINE. 


PHILADELPHIA: 
1 8 90. 


DISPLACEMENTS  OF  THE  UTERUS. 

By  E.  C.  DUDLEY,  A.  B.,  M.  D. 


The  title  of  this  article  is  not  to  be  taken  in  a restricted  sense,  inas- 
much as  the  uterus  is  anatomically  so  connected  with  adjacent  organs  that 
the  displacements  of  the  uterus  cannot  be  intelligently  considered  or  satis- 
factorily presented  without  at  the  same  time  incidentally  taking  into 
account  the  displacements,  causative,  resultant,  or  concurrent,  of  the 
ovaries,  Fallopian  tubes,  rectum,  vagina,  and  bladder. 


Normal  Location  and  Position  of  the  Uterus.1 

In  the  woiks  on  anatomy  and  gynecology  which  we  are  accustomed  to 
consult  the  uterus  is  represented  as  having  a straight  or  nearly  straight 
canal — as  lying  about  midway  between  the  symphysis  pubis  and  the  hollow 
of  the  sacrum,  its  axis  corresponding  to  that  of  the  pelvic  inlet.  They 
generally  agree  that  its  position  is  one  of  slight,  and  only  slight,  ante- 
version  ; some  admit  that  slight  anteflexion  may  not  be  injurious,  but 
most  would  pronounce  the  organ  anteverted  or  anteflexed  to  a degree  that 
would  endanger  health  if  by  conjoined  manipulations  its  anterior  wall 
could  be  felt  through  the  anterior  wall  of  the  vagina.  The  classical  idea  of 
the  normal  position  of  the  uterus  presupposes  a distended  bladder  and 
rectum  occupying  the  anterior  and  the  posterior  thirds  of  the  pelvic 
cavity.  Such  an  arrangement  would  leave  for  the  uterus  only  the  inter- 
mediate space,  and  would  constitute  a condition  seldom  or  never  realized 
in  health. 

Suppose  a straight  line  coincident  with  the  vesico- vaginal  wall  (Fig.  1) 
to  be  continued  through  the  cervix  to  the  sacrum.  This  line  represents 
approximately  the  antero-posterior  diameter  of  the  pelvis.  The  length 
of  the  vesico-vaginal  wall  is  two  and  a half  inches,  and,  supposing  the 
cervix  to  be  just  midway  between  the  symphysis  and  the  sacrum,  the 
distance  from  its  posterior  wall  to  the  sacrum  must  also  be  two  and  a 
half  inches.  Add  to  the  sum  of  these  two  parts  of  this  antero-posterior 
diameter  one  inch  for  the  cervix,  and  the  antero-posterior  diameter  of  the 
pelvis  becomes  six  inches  instead  of  the  normal  four  and  one-third  ; which 
proves  that  the  cervix  must  normally  be  much  nearer  to  the  hollow  of 

1 The  importance  of  a distinction  between  location  and  position  will  become  apparent 
hereafter:  by  the  former  is  meant  the  situation  of  the  organ  regardless  of  its  attitude,  by 
the  latter  is  meant  the  attitude  alone.  To  change  an  object  from  one  place  to  another  is 
to  change  its  location ; to  turn  it  over  or  bend  it  upon  itself  is  to  change  its  position. 

147 


803801 


148 


DISPLA CEMENTS  OF  THE  UTERUS. 


the  sacrum  than  to  the  symphysis.  Since  the  length  of  the  vesico- vaginal 
wall  plus  the  diameter  of  the  cervix  measures  three  and  one-half  inches, 
it  follows  that  the  distance  from  the  posterior  wall  of  the  cervix  to  the 
hollow  of  the  sacrum  must  be  the  difference  between  four  and  one-third 
and  three  and  one-half  inches,  or  five-sixths  of  an  inch. 

Again,  suppose  the  uterus  (Fig.  1)  to  be  carried  bodily  upward  and 
backward,  its  axis  remaining  the  same,  until  the  cervix  reach  its  normal 

Fig.  1. 


position  near  the  hollow  of  the  sacrum ; then  would  the  body  of  the 
uterus  impinge  upon  the  bony  sacrum.  It  is  therefore  clear  that  the 
anteversion  must  be  the  normal  position,  because  the  uterus  and  sacrum 
would  otherwise  occupy  the  same  space. 

Fig.  2 represents,  according  to  Schultze,1  the  location  and  position  of 
the  virgin  uterus  and  its  surroundings,  the  bladder,  rectum,  and  vagina 
being  empty  and  collapsed.  The  angle  of  about  90°  which  the  cervix 
forms  with  the  vagina  measures  the  forward  inclination  of  the  cervix, 
but  is  subject  to  slight  variations  in  consequence  of  the  physiological 

1 Archiv  fur  Gynakologie,  1875,  Band  viii.  p.  134,  and  Lageveranderungen  der  Gebarmutter , 
Berlin,  1881. 

Ely  Van  de  Warker  makes  a full  and  critical  study  of  the  normal  movements  of  the 
unimpregnated  uterus  in  the  N.  Y.  Medical  Jouimal,  xxi.  p.  337,  and  of  the  normal  posi- 
tion and  movements  of  the  unimpregnated  uterus  in  the  American  Joumcd  of  Obstetrics , 
zi.  p.  314.  His  conclusions  substantially  agree  with  those  of  Schultze. 

Frank  P.  Foster  ( American  Journal  of  Obstetrics,  xiii.  p.  30)  presents  a valuable  paper 
giving  a resum6  of  the  literature,  with  original  observations,  in  which  he  takes  exception? 
in  part  to  the  views  of  Schultze. 


NORMAL  MOVEMENTS  OF  THE  UTERUS. 


149 


movements  of  the  uterus.  The  body  is  furthermore  bent  forward  upon 
the  cervix,  so  that  its  anterior  surface  rests  upon  the  empty  bladder.  The 
angle  of  the  normal  anteflexion,  according  to  careful  measurements  by 
Schultze,  is  about  48°  ; Fritsch  says  that  90°  is  the  physiological  limit. 
This  question  will  be  further  considered  under  the  subject  of  pathological 
anteflexions. 


Normal  Movements  of  the  Uterus. 

Strictly,  the  uterus  can  have  no  absolutely  normal  position  or  location, 
because  it  has  a certain  normal  range  of  movements  which  depend  to  some 
extent  upon  respiration,  intra-abdominal  forces,  and  locomotion,  but  more 


Fig.  2. 


The  Correct  Representation  of  the  Pelvic  Organs. 

especially  upon  the  varying  quantity  of  material  in  the  rectum  and  bladder. 
Its  normal  position,  then,  varies  within  the  limits  of  its  normal  move- 
ments. If  the  body  of  the  uterus  rest  upon  the  bladder,  it  must  rise  as 
the  bladder  becomes  distended,  and,  conversely,  if  the  urine  be  drawn 
through  a catheter  while  the  woman  is  lying  on  her  back,  the  uterus,  not- 
withstanding the  opposing  influence  of  its  own  weight,  immediately  fol- 
lows the  receding  wall  of  the  bladder  and  returns  through  an  angle  of 
45°,  or  possibly  even  90°,  to  its  accustomed  position.  The  dotted  lines 
in  Fig.  2 indicate  the  degree  of  version  and  flexion  consequent  upon  the 
varying  quantity  of  fluid  in  the  bladder. 


150 


DISPLACEMENTS  OF  THE  UTERUS. 


The  full  rectum  forces  the  uterus  in  the  opposite  direction,  toward  the 
symphysis,  and  thereby  counteracts  the  influence  of  the  bladder.  This 
anterior  movement  is,  however,  somewhat  limited,  and  is  confined  to  the 
cervical  portion,  except  when  the  body  has  been  forced  back  into  close 
proximity  with  the  rectum  by  the  over-distended  bladder. 


Normal  Supports  of  the  Uterus. 

The  uterus  is  maintained  in  its  normal  position  and  location  by  the 
following  agents : 

a.  The  uterine  ligaments  ; 

b.  The  pelvic  floor.1 

a.  Physiologically,  these  ligaments  are  relaxed ; the  state  of  tension 
would  be  pathological ; they  do  not  fix  the  uterus ; they  only  tend  to 
limit  its  movements  to  their  normal  range.  Backward  displacement  of 
the  body  is  resisted  by  the  round  ligaments,  backward  displacement  of 
the  cervix  by  the  utero-vesical  ligaments  and  by  the  vesico- vaginal  wall. 
Forward  and  downward  displacements  are  resisted  by  the  utero-sacral 
ligaments,  and  excessive  lateral  motion  by  the  broad  ligaments.  This 
restraining  power  is  doubtless  greater  in  the  utero-sacral  than  in  any  of 
the  other  ligaments. 

b.  The  pelvic  floor,  which  is  the  chief  support  of  the  uterus,  is  divided 
into  two  segments,  the  pubic  and  the  sacral.  The  pubic  segment2  is  com- 
posed of  bladder,  urethra,  anterior  vaginal  wall,  and  bladder  peritoneum. 
It  is  attached  in  front  to  the  symphysis  pubis  and  laterally  to  the  anterior 
bony  walls  of  the  pelvis.  The  sacral  segment3  is  composed  of  rectum, 
perineum,  posterior  vaginal  wall,  and  strong  tendinous  and  muscular  tis- 
sue. It  is  attached  to  the  coccyx,  to  the  sacrum,  and  to  the  posterior  wall 
of  the  bony  pelvis. 

Permeating  the  pelvic  floor  in  all  directions,  entering  into  the  compo- 
sition of  its  single  parts,  binding  them  together,  and  sending  its  processes 
to  the  bony  pelvis,  is  the  pelvic  connective  tissue,  upon  the  integrity  of 
which  depends  the  integrity  of  the  pelvic  floor  as  a uterine  support.  Its 
pernicious  influence  as  a pathological  factor  will  be  considered  hereafter. 
The  old  idea  that  the  uterus  is  supported  by  the  vaginal  walls  or  by  the 
perineum  or  by  the  uterine  ligaments  is  obsolete;  they  are  important  parts 
of  the  pubic  and  sacral  segments,  and  as  such  contribute  their  share,  but 
the  pelvic  floor  as  a whole  supports  the  uterus.  The  various  uterine  sup- 
ports are  to  a great  extent  the  seat  of  motor  influence.  They  consequently 
not  only  resist  excessive  movement,  but  also  serve  to  return  the  organ  from 
its  physiological  migrations. 

Definition  and  Nomenclature  of  Displacements. — In  the  fore- 
going pages  the  normal  location,  position,  movements,  and  supports  of 
the  uterus  have  been  defined.  Those  conditions  are  pathological  which 
induce  changes  to  positions  or  locations  beyond  the  defined  limits,  or 
which  so  fix  the  organ  that  its  normal  movements  are  prevented.  The 
displacements  are  divided  into  mal-locations  and  malpositions. 

The  mal-locations  in  which  the  entire  uterus  occupies  a place  outside 

1 For  a description  of  the  female  pelvic  floor  see  Hart’s  Atlas. 

2 Hart  and  Barbour’s  Manual  of  Gynecolor/y. 


3 Ibid. 


NORMAL  MOVEMENTS  OF  THE  UTERUS. 


151 


its  normal  limits  are  as  follows  : ascent,  retro-location,  ante-location,  lat- 
eral location,  descent. 

The  malpositions  are  determined  by  excessive  change  in  the  inclination 
of  the  uterine  axis.  They  are  further  divided  into  flexions,  in  which  the 
organ  is  bent  upon  itself  in  an  abnormal  degree,  manner,  or  direction  ; 
and  versions,  in  which  the  axis  of  the  unflexed  uterus  inclines  in  an 
abnormal  degree  or  direction.  The  malpositions  are  retroversion,  retro- 
flexion, lateral  version,  lateral  flexion,  anteversion,  anteflexion. 

Symptoms  and  Diagnosis  in  General. — Each  variety  of  displace- 
ment may  be  indicated  by  its  own  group  of  symptoms  and  physical  signs. 
These  will  be  presented  in  the  study  of  the  special  lesions.  To  avoid 
repetition,  those  symptoms  and  signs  which  pertain  to  no  special  displace- 
ment, but  which  belong  to  all  alike,  will  be  mentioned  at  once.  They 
may  arise  either  from  the  displacement  itself  or  from  its  possible  complica- 
tions, of  which  the  following  are  examples.:  Metritis,  ovaritis,  salpingitis, 
atresia  and  stenosis,  cystitis,  vesical  catarrh,  rectitis,  rectal  catarrh,  peri- 
uterine cellulitis  and  peritonitis,  uterine  catarrh,  tumors,  cicatrices,  etc. 

Uterine  displacement  may  be  a cause  or  an  effect  of  associated  compli- 
cations, or  together  with  them  it  may  be  a concurrent  result  of  some 
common  cause,  or  it  may  have  had  primarily  no  pathological  connection 
with  them.  The  symptoms  of  displacement  refer  to  the  pelvic  organs  or 
to  the  nervous  system.  Among  the  symptoms  which  refer  to  the  pelvic 
organs  are — difficulty  in  walking  and  standing;  pelvic  pain,  more  or  less 
constant;  dysmenorrhcea,  menorrhagia,  sterility,  frequent  abortion,  con- 
stipation, painful  or  difficult  defecation,  dysuria,  polyuria,  tenesmus,  etc. 
Among  the  symptoms  which  refer  to  the  nervous  system  are — neuralgia 
in  various  parts,  paralysis,  hysteria,  nervous  dyspepsia,  anaemia,  chlorosis, 
spinal  irritation,  etc. 

The  final  diagnosis  must  always  depend  upon  direct  examination  of 
the  uterus  itself.  The  first  division  of  the  above  group  of  symptoms  is 
not  likely  to  escape  notice  as  indicative  of  displacement,  but  the  nervous 
symptoms  are  constantly  disregarded  or  treated  without  reference  to  their 
possible  pelvic  origin.  The  frequent  dependence  of  these  nervous  phe- 
nomena upon  displacement  is  proved  by  their  persistence  in  many  cases 
after  ordinary  treatment,  by  their  prompt  disappearance  upon  permanent 
replacement  and  retention  of  the  uterus  by  mechanical  means,  and  by 
their  equally  prompt  recurrence  upon  removal  of  the  support.  The  pres- 
ence, therefore,  of  the  second  division  of  the  group  or  any  part  thereof, 
even  though  the  first  be  absent,  will  justify,  may  even  necessitate,  a care- 
ful investigation  into  the  state  of  the  pelvic  organs. 

That  examination  which  results  only  in  giving  the  name  to  a special 
variety  of  displacement,  and  does  not  include  the  complicating  lesions, 
would  not  furnish  a sufficient  guide  to  the  therapeutic  indications,  and  is 
therefore  inadequate.  The  successful  treatment,  for  instance,  of  an  ante- 
flexion dependent  upon  inflammation  of  the  utero-sacral  ligaments  must 
include  the  removal  of  the  inflammation. 

An  important  prerequisite  to  examination  is  the  absence  of  material 
in  the  rectum  and  bladder.  The  full  rectum  distorts  the  vaginal  walls, 
deprives  the  examiner  of  the  space  necessary  for  the  introduction  of  the 
speculum,  and  throws  the  uterus  out  of  its  accustomed  position.  Much 
more  troublesome  is  the  presence  of  even  a small  quantity  of  urine  in 


152 


DISPLACEMENTS  OF  THE  UTERUS. 


the  bladder,  because  it  causes  the  patient  to  render  the  abdominal  muscles 
tense  when  the  hand  is  placed  over  the  lower  portion  of  the  abdomen  for 
bimanual  palpation,  and  makes  it  impossible  to  engage  the  uterus  between 
the  hand  and  the  examining  finger.  The  distended  bladder  by  pushing 
the  uterus  upward  and  backward  makes  bimanual  palpation  almost  use- 
less. It  is  not  surprising  that  conflicting  opinions  are  common,  when  one 
day  the  patient  is  examined  with  rectum  and  bladder  full,  another  day 
empty;  one  day  in  the  dorsal,  another  in  Sims’s  or  the  knee-chest  posi- 
tion ; one  day  with  the  cylindrical  or  bivalve  speculum,  another  day  with 
Sims’s  or  Simon’s. 

For  digital  examination  the  dorsal  position  is  preferred  : the  patient 
should  be  drawn  close  to  the  edge  of  a bed,  or  preferably  a table,  the 
thighs  being  flexed,  the  feet  about  fifteen  inches  apart,  and  the  knees 
widely  separated.  The  examiner  should  stand  facing  the  patient,  never 
at  the  side.  The  index  finger,  of  the  left1  hand,  lubricated  with  vaseline 
or  oil,  then  slowly  advances  over  the  perineum  into  the  vagina,  noting  the 
condition  of  the  perineum,  the  presence  or  absence  of  cicatrices  or  of  sub- 
involution of  the  vagina  or  perineum,  the  capacity  of  the  vagina,  the  con- 
dition, size,  and  direction  of  the  cervix,  its  distance  from  the  sacrum  and 
vulva,  its  mobility  or  fixation.  Now,  for  the  first  time,  the  right  hand 
is  pressed  well  down  behind  the  pubes,  and  the  uterus  is  engaged  between 
it  and  the  examining  finger.  (See  Figs.  16  and  17.)  In  this  way  the 
examiner  may  determine  more  accurately  the  position,  location,  and  size 
of  the  entire  organ ; may  detect  the  possible  presence  of  complicating 
tumors,  both  inflammatory  and  non-inflammatory ; may  also  note,  if 
possible,  the  location  and  condition  of  the  ovaries,  which,  especially  in 
the  posterior  displacements,  are  liable  to  be  prolapsed  and  excessively 
sensitive,  and  to  constitute,  therefore,  a most  intractable  complication. 
The  index  finger  sweeps  around  the  cervix  in  search  of  tender  places 
which  may  be  the  result  of  former  cellulitis  or  the  expression  of  some 
neurosis.  Above  all,  the  digital  examination  requires  a light,  gentle, 
delicate  touch. 

In  exploring  the  uterine  cavity  to  learn  its  position  the  fine  silver-wire 
probe  of  Emmet — not  the  sound — should  be  used.  The  uterus,  if  freely 
movable,  is  liable  to  be  thrown  out  of  its  accustomed  position  by  the 
heavier,  unyielding  sound.  The  sound  also  causes  much  more  pain  and 
exposes  the  patient  to  great  danger  of  cellulitis.  The  frequent  lighting 
and  relighting  of  pelvic  inflammation  by  injudicious  slight  manipulations 
of  the  uterus  doubtless  led  Emmet  to  the  utterance  of  a prophecy  which 
ought  to  become  classical : “ A great  advance  in  the  treatment  of  the 
diseases  of  women  will  be  made  whenever  practitioners  become  so  im- 
pressed with  the  significance  of  cellulitis  as  to  apprehend  its  existence 
in  every  case.  The  successful  operator  in  this  branch  of  surgery  will 
always  be  on  the  lookout  for  the  existence  of  cellulitis,  and  take  measures 
to  guard  against  its  occurrence.” 

When  the  probe  or  the  sound  is  used  without  the  speculum,  the  patient 

1 The  left-hand  method  of  examination  is  incomparably  superior  to  the  right.  The 
palmar  surface  of  the  index  finger  is  more  easily  directed  toward  the  left  side  of  the 
pelvis,  which  is  especially  subject  to  disease.  Its  tactile  sense  is  more  acute  and  more 
easily  educated.  The  stronger  right  hand  should  be  free  to  palpate  the  surface  of  the 
abdomen  in  conjoined  manipulation. 


LATERAL  LOCATIONS  OF  THE  UTERUS. 


153 


should  be  on  the  back  and  the  index  finger  of  the  left  hand  should  be 
used  as  a guide.  The  bivalve  and  cylindrical  specula  are  almost  useless 
in  explorations  of  the  interior  of  the  uterus.  The  exploration  is  most 
effectually  and  gently  made  with  Sims’s  speculum,  the  patient  being  in 
the  left  latero-prone  position.  In  some  cases  the  probe  cannot  be  passed 
by  any  other  method. 


Ascent  of  the  Uterus. 

This  mal-location  may  result  from  traction  above  or  from  pressure 
below.  The  organ  may  be  drawn  upward  and  backward  by  shortening 
of  the  utero-sacral  ligaments,  which  results  from  inflammation  and  which 
usually  induces  a troublesome  form  of  anteflexion.  The  enlarged  preg- 
nant uterus  sometimes  becomes  attached  by  adhesive  inflammation  to  a 
portion  of  the  peritoneum  in  one  of  the  higher  zones  of  the  pelvis  or  in 
the  abdomen,  and  the  organ  may  consequently  remain  fixed  in  its  elevated 
position  after  involution.  A tumor  connected  with  the  uterus  or  its 
appendages  which  has  grown  too  large  to  be  retained  in  the  pelvis  may, 
upon  rising  into  the  abdomen,  drag  the  uterus  with  it.  Pressure  below 
may  come  from  excessive  distension  of  the  rectum  or  bladder,  or  from  a 
large  accumulation  of  menstrual  fluid  in  the  vagina,  or  from  a tumor 
originating  in  any  portion  of  the  pelvis  below  the  level  of  the  uterus. 
In  diagnosis,  prognosis,  and  treatment  this  displacement  is  wholly  sub- 
ordinate to  the  more  significant  lesions  of  which  it  is  only  the  incidental 
result. 


Retro-location  of  the  Uterus. 

The  uterus  may  be  forced  back  into  a post-normal  location  by  the 
presence  of  a tumor  in  front  or  by  the  distended  bladder,  or  it  may  be 
drawn  back  and  fixed  by  peritoneal  adhesions.  Retro-location  is  liable 
to  induce  vesical  irritation  by  putting  the  vesico-vaginal  wall  on  the 
stretch  and  thereby  dragging  on  the  neck  of  the  bladder.  This  intract- 
able symptom  is  sometimes  relieved  by  Emmet’s  buttonhole  operation  of 
urethrotomy,  for  an  account  of  which  see  section  on  Anteflexion.  This 
operation  would  obviously  be  applicable  also  for  the  relief  of  the  same 
symptom  when  caused  by  ascent  of  the  uterus. 


Ante-location  of  the  Uterus. 

The  causes  of  this  displacement  are  similar  to  those  which  produce 
retro-location ; they  are — distension  of  the  rectum,  post-uterine  haematocele, 
post-uterine  tumors,  and  peritoneal  adhesions.  Ante-location  often  causes 
vesical  irritation,  consequent  upon  the  invasion  by  the  uterus  of  that  space 
which  belongs  to  the  bladder. 


Lateral  Locations  of  the  Uterus. 

The  entire  uterus  is  often  displaced  to  the  right  or  the  left  by  a tumor 
or  by  an  inflammatory  exudate.  The  latter  occurs  as  a product  of  cellu- 


154 


DISPLACEMENTS  OF  THE  UTERUS. 


litis,  usually  in  the  left  broad  ligament,  and  crowds  the  organ  toward  the 
opposite  side  of  the  pelvis.  After  resolution  the  ligament,  shortened  by 
inflammatory  contraction,  draws  the  uterus  to  the  affected  side  and  fixes 
it  there.  Lateral  displacement  from  this  cause  often  accompanies  lacera- 
tion of  the  cervix,  the  cellulitis  having  occurred  on  the  side  corresponding 
to  the  laceration. 


Descent  or  Prolapse  of  the  Uterus. 

The  nature  of  this  displacement  is  clearly  indicated  by  its  name.  It 
is  convenient  to  distinguish  three  degrees  of  descent : In  the  first  the 
organ  is  displaced  downward  and  forward  until  sufficient  space  has  been 
gained  between  the  cervix  and  the  sacrum  to  permit  the  body  to  turn 
back  into  extreme  retroversion  ; in  the  second  the  cervix  descends  to  the 
vulva;  in  the  third  the  uterus  protrudes  partially  or  wholly  through  the 
vulva,  constituting  a condition  sometimes  called  procidentia. 

Etiology  and  Clinical  History. — Descent  may  be  the  result  of 
any  or  all  of  the  following  causes : I.  Pressure  from  above ; II.  Weak- 
ening of  the  supports ; III.  Increased  weight  of  the  uterus ; IV.  Trac- 
tion from  below.  Either  of  the  above  conditions  being  the  primary  cause, 
the  others  singly  or  combined  may  result. 

I.  Pressure  from  above  may  depend  upon  the  presence  of  a pelvic  or 
abdominal  tumor,  ascites,  fecal  accumulations,  tight  or  heavy  clothing, 
etc. 

II.  The  uterine  supports  may  be  weakened  and  relaxed  in  consequence 
of  subinvolution,  senile  atrophy,  abnormally  large  pelvis,  increased  weight 
of  the  uterus,  pressure  from  above,  traction  from  below,  etc. 

III.  Increased  weight  of  the  uterus  may  be  caused  by  congestion,  sub- 
involution, hypertrophy,  hyperplasia,  pregnancy,  fluid  in  the  endomet- 
rium, uterine  tumors,  etc. 

IV.  Traction  from  below  may  be  due  to  vaginal  cicatrices,  abnormally 
short  vagina,  falling  of  the  pelvic  floor,  etc. 

Obviously,  descent  of  the  vesico-  and  recto- vaginal  walls,  or,  more 
comprehensively,  the  sacral  and  pubic  segments  of  the  pelvic  floor, 
involves  also  concurrent  descent  of  the  uterus.  Descent  of  the  vagina, 
therefore,  must  be  studied  in  connection  with  the  descent  of  the  uterus. 
Excessive  descent  of  the  vaginal  walls  usually  originates  with  partu- 
rition. 

In  labor  the  anterior  wall  of  the  vagina  is  so  depressed,  stretched,  and 
shortened  by  the  advancing  head  that  during  and  after  the  second  stage 
the  anterior  lip  of  the  cervix  may  be  seen  behind  the  urethra.  If  the 
puerperium  progress  favorably,  with  prompt  involution  of  the  uterus, 
vagina,  perineum,  and  peritoneum,  the  relaxation  of  the  vesico- vaginal 
wall  and  of  the  utero-sacral  supports  disappears  and  the  uterus  resumes 
its  normal  multiparous  location  and  position.1  But  if  the  enlarged  uterus 
remain  in  the  long  axis  of  the  vagina,  with  its  fundus  incarcerated  in  the 
hollow  of  the  sacrum  between  the  utero-sacral  ligaments,  and  with  its 
sacral  supports  so  stretched  that  they  cannot  recover  their  contractile 
power,  and  with  involution  of  all  the  pelvic  organs  arrested,  the  descent 

1 The  anteflexion  of  the  multiparous  uterus  is  less  than  that  of  the  virgin. 


DESCENT  OR  PROLAPSE  OF  THE  UTERUS. 


155 


may  not  only  persist,  but  may  even  progress  with  constantly  increasing 
cystocele  to  the  third  degree  of  prolapse.  The  downward  influence  of 
the  above  conditions  may  be  materially  increased  by  rupture  of  the  peri- 
neum, and  consequent  prolapse  of  the  recto-vaginal  wall  into  a pouch 
called  rectocele. 

In  the  great  majority  of  cases  of  complete  prolapse  the  posterior 
vaginal  wall  in  its  descent  is  peeled  off  from  the  rectum,  leaving  the 

Fig.  3. 


latter  in  its  normal  position.  In  rare  instances  the  lower  portion  of  the 
rectum  is  also  found  to  have  extruded  in  extreme  rectocele,  making  a 
pouch  below  and  in  front  of  the  anus,  where  fecal  matter  may  accumulate 
and  remain  in  hard  scybalse. 

Obviously,  complete  prolapse  of  the  uterus  is  only  an  incident  to  the 
prolapse  of  the  pelvic  floor.  The  whole  mechanism  is  in  all  respects 
analogous  to  that  of  hernia.  The  extruded  mass  drags  after  it  a per- 
itoneal sac,  which,  hernia-like,  contains  small  intestine.  This  sac 
forces  its  way  to  the  pelvic  outlet  and  extrudes  through  the  vulva, 
having  the  inverted  vagina  for  its  covering. 

In  descent  of  the  first  degree  the  location  of  the  uterus  is  either 
changed  to  a lower  level,  the  position  remaining  normal,  or,  as  is  more 
common,  the  cervix  having  moved  nearer  to  the  symphysis  and  the 
organ  turns  back  into  retroversion.  In  a given  case  suppose  the  vag- 
inal walls  from  some  cause  to  have  become  relaxed  and  to  have  settled 


156 


DISPLACEMENTS  OF  THE  UTERUS. 


to  a lower  level  in  the  pelvis.  As  an  associated  fact  the  uterus  to  which 
these  walls  are  attached  must  then  also  occupy  a place  correspondingly 
nearer  to  the  vulva — i.  e.  the  location  of  the  uterus  has  changed,  so  that 
space  enough  intervenes  between  it  and  the  hollow  of  the  sacrum  for  the 
former  to  turn  back  into  the  position  of  retroversion  or  retroflexion. 
If,  on  the  contrary,  the  descending  uterus  still  maintains  its  normal  ante- 
version  and  anteflexion,  it  must  occupy  space  which  belongs  to  the  blad- 
der. The  vesical  irritation  consequent  upon  this  mal-location  has  gen- 
erally been  ascribed  to  the  anteversion  and  anteflexion,  which  are  therefore 
oftentimes  wrongly  pronounced  pathological.  The  prompt  relief  which 
follows  permanent  replacement  of  the  organ  in  the'normal  location,  even 
though  in  so  doing  its  anteposition  be  exaggerated,  proves  that  the  symp- 
toms depend  upon  the  mal-location,  not  upon  the  anteposition.  The  im- 
portance of  a clear  distinction,  therefore,  between  location  and  position 
becomes  apparent.  Vesical  irritation,  moreover,  is  sometimes  caused  by  the 
dragging  of  the  uterus  upon  the  neck  of  the  bladder.  This  traction  occurs 
not  only  in  ascent,  but  also  when  the  organ  descends  below  a certain  level. 

In  the  foregoing  paragraphs  traction  due  to  the  falling  pelvic  floor  has 
been  discussed  as  a cause  of  descent.  The  impairment  of  the  uterine 
supports  may,  however,  be  such  that  instead  of  falling  and  dragging  the 

Fig.  4. 


Showing  Extreme  Descent  of  the  Uterus  and  of  the  Pelvic  Floor,  and  the  Hernial  Character  of  the 

Lesion. 

uterus  after  them,  they  simply  permit  it  to  descend  along  the  vaginal  canal 
by  the  force  of  its  own  weight,  and  to  carry  with  it  the  reduplicated 
vaginal  walls.  This  influence  is  generally  enforced  by  the  increased 
weight  of  the  diseased  organ.  The  vagina  more  readily  becomes  a track 
for  the  descending  uterus  when  from  any  cause  the  normal  forward  direc- 
tion of  the  vaginal  canal  changes  toward  the  vertical : this  change  may 
occur  either  as  the  result  of  a forward  displacement  of  its  upper  extremity, 
involving  anteposition  of  the  cervix,  or  of  a retro-displacement  of  its 


DESCENT  OR  PROLAPSE  OF  THE  UTERUS. 


157 


lower  extremity  in  consequence  of  rupture  or  subinvolution  of  the  peri- 
neum. (See  Fig.  3.)  Descent  in  the  track  of  the  vagina  is  obviously 
combined  with  some  degree  of  retroversion,  because  the  axes  of  the  uterus 
and  vagina  then  correspond. 

The  pathological  anatomy  may  involve  all  the  displaced  organs. 
The  circulation  throughout  the  pelvis  is  impeded  by  traction  upon  the 
vessels,  and  the  entire  pelvic  contents  therefore  become  the  subject  of 
venous  congestion,  with  consequences  disastrous  to  local  innervation  and 
nutrition. 

The  ovaries  may  suffer  concurrent  displacement,  with  resulting  inflam- 
matory and  cystic  enlargement.  The  peritoneum  which  enters  into  the 
formation  of  the  uterine  ligaments  and  of  the  pelvic  floor  is  dragged  along 
with  the  uterus. 

The  vagina  is  hypertrophied  and  swollen.  Its  mucous  membrane 
becomes  the  seat  of  acute  vaginitis  and  chronic  catarrh.  In  the  third 
degree  of  descent  the  exposed  vagina,  no  longer  lubricated  by  the  nor- 
mal secretions  of  the  uterus,  becomes  dry,  parchment-like,  oedematous, 
eroded,  and  ulcerated.  Sometimes  the  cul-de-sac  of  Douglas  is  distended 
by  downward  pressure  of  the  intestines,  by  a small  tumor,  or  by  ascitic 
fluid,  and  a consequent  hernial  sac  may  protrude  into  the  vagina  through 
some  portion  of  the  posterior  vaginal  fornix.  The  anterior  fornix  is  sub- 
ject to  a similar  accident.  These  conditions  are  designated  enterocele 
vaginalis,  anterior  and  posterior. 

The  rectum  and  bladder  are  subject  to  inflammation  and  chronic  catarrh, 
and  the  bladder  especially  to  concurrent  descent.  The  uterus  may  be  en- 
larged from  any  one  or  all  of  a variety  of 
causes — congestion,  subinvolution,  hypertro- 
phy, and  hyperplasia.  Its  cervix  is  often 
the  seat  of  extreme  erosion  or  so-called  ulcer- 
ation. The  endometrium,  in  order  to  relieve 
the  organ  of  its  surplus  blood,  gives  forth 
an  excessive  secretion  of  mucus,  which  upon 
being  increased  in  quantity  becomes  vitiated 
in  quality.  This  is  termed  uterine  catarrh. 

The  enlargement  of  the  uterus  often  pertains 
more  to  the  cervix  than  to  the  body,  espe- 
cially in  prolapse  of  the  second  and  third 
degrees.  An  explanation  of  this  may  be 
found  in  Figs.  5 and  6. 

Apparent  elongation  and  disproportionate 
circular  enlargement  of  the  cervix  are  con- 
ditions which  almost  every  standard  author 
wrongly  calls  hypertrophic  elongation  and 
circular  hypertrophy.  The  question  of  elon- 
gation is  easily  settled  by  placing  the  patient  ^vag^Lfcanai^fhowin^thl  Redupii 
in  the  knee-chest  position.  Then  the  uterus  and°iTJ£ 

by  its  own  weight  falls  toward  the  diaphragm,  pears  to  be  at  x'  and  z[.  The  appar- 

/ . p i i ii  y i ent  increase  of  length  in  the  vaginal 

the  vagina  untolds,  and  the  apparent  utero-  portion  of  the  cervix  due  to  the  redu- 
vaginal  attachment  X'  Z'  (Figs.  5 and  6)  &‘Ta Dd z Z ‘Usl”“ 
disappears,  disclosing  the  actual  attachment, 

X Z.  Further,  the  point  of  the  sound,  passed  into  the  bladder  while  the 


Fig.  5. 


158 


DISPLACEMENTS  OF  THE  UTERUS. 


Fig.  6. 


cervix  is  exposed  by  Sims’s  speculum,  may  be  placed  against  the  anterior 
wall  of  the  cervix  at  Z,  which  would  be  impossible  if  the  attachment  were 
at  Z'. 

The  comparatively  small  amount  of  hypertrophy  in  disproportionate 
circular  enlargement  is  proved  by  the  operation  of  trachelorraphy  or  by 

bringing  the  points  a and  b (Fig.  6)  to- 
gether with  uterine  tenacula,  the  organ 
being  exposed  by  Sims’s  speculum.  Then 
the  out-rolled  intracervical  mucous  tissues 
are  rolled  back,  the  proper  diameter  of  the 
cervix  is  restored,  and  a laceration  on  one 
or  both  sides,  extending  past  the  vaginal 
attachment,  becomes  apparent. 

Hypertrophy  or  hyperplasia  usually 
causes  a nearly  symmetrical  enlargement 
of  the  entire  organ.  At  any  rate,  those 
cases  in  which  the  reduplication  of  the 
vaginal  walls  does  not  almost  entirely 
explain  the  great  elongation  so  called,  or 
in  which  great  disproportionate  circular 
enlargement  has  not  been  caused  by  lace- 
ration of  the  cervix,  are  the  rare  excep- 
tions. The  great  merit  of  having  secured 
general  assent  to  the  foregoing  proposition, 
and  of  having  given  to  the  subject  a new 
and  right  direction,  must  be  accorded  to 
Emmet.  The  cervix  now  is  seldom  am- 
putated except  for  malignant  disease. 

Congestion  of  the  uterus  consequent 
upon  obstruction  in  the  stretched  and  dis- 
placed veins  is  often  so  extreme  as  to  in- 
duce a state  analogous  to  erection.  Meas- 
urements by  the  probe  just  before  and  a 
few  minutes  after  replacement  generally 
show  an  appreciable  decrease  in  the 
length  of  the  uterine  canal.  If  the  pro- 
lapse has  been  of  the  third  degree,  the 
difference  may  amount  to  one  or  even 
two  inches.  It  is  important  not  to  confound  the  enlargement  of  con- 
gestion with  increase  in  the  solid  constituents  of  the  organ. 

Symptoms  and  Course. — A dragging  sensation  and  pelvic  and  abdom- 
inal pain  are  generally  present.  Rectocele  and  cystocele  and  rectal  and 
vesical  catarrh  often  cause  painful  and  severe  functional  disturbances  of 
the  rectum  and  bladder.  In  descent  of  the  third  degree  excoriations  of 
the  exposed  vagina  and  cervix  sometimes  cause  extreme  suffering.  The 
course  is  ordinarily  chronic,  but  attacks  of  acute  vaginitis  and  pelvic 
peritonitis  are  not  uncommon.  The  peritonitis  sometimes  effects  a spon- 
taneous cure  by  peritoneal  adhesions  which  fasten  the  uterus  in  an  ele- 
vated position  and  hold  it  permanently.  The  symptoms  of  descent  may 
be  so  severe  as  to  necessitate  absolute  rest  in  bed.  In  other  cases  they  are 
often  attended  with  very  little  discomfort. 


Descent  of  the  Uterus,  showing  Excessive  Cir- 
cular Enlargement  of  the  Lacerated  Cervix, 
consequent  upon  Reduplication  of  the  Vag- 
inal Walls  and  Out-rolling  of  Intracervi- 
cal Tissues.  The  divided  fragments  of  the 
os  externum  are  at  a and  b.  The  curved  lines 
forming  the  angles  1,  2,  3,  4,  and  5 indicate 
the  gradual  process  of  the  eversion.  The 
angle  of  the  laceration  at  point  1 has  been 
forced  down  by  the  swelling  and  out-rolling 
of  the  mucous  and  submucous  tissues  of  the 
cervix  to  point  5.  The  apparent  os  exter- 
num is  at  point  5.  The  utero-vaginal  at- 
tachment X and  Z seems  to  be  at  X'  and 
Z'.  The  vaginal  portion  of  the  cervix  there- 
fore appears  much  larger  and  longer  than 
it  actually  is. 


DESCENT  OB  PROLAPSE  OF  THE  UTERUS. 


159 

Diagnosis  is  by  inspection,  palpation,  and  exploration.  The  prolapsed 
uterus  may  be  distinguished  from  cystocele,  rectocele,  inverted  uterus,  and 
fibroid  tumor  by  the  presence  of  the  os  externum.  The  sound  may  be 
passed  through  the  urethra  into  the  cystocele,  and  the  finger  through  the 
anus  into  the  rectocele.  The  length  of  the  uterus  may  be  determined  by 
the  sound,  the  size,  shape,  position,  extent  of  descent,  and  difficulty  of 
replacement  by  conjoined  manipulation. 

Prophylaxis. — This  requires  such  measures  during  labor  as  may  be 
necessary  to  prevent  long  and  powerful  pressure  upon  the  pelvic  floor. 
After  labor  any  injury  to  the  perineum  should  be  promptly  repaired. 
The  vagina  should  be  kept  clean  by  irrigations.  The  urine,  if  necessary, 
should  be  regularly  drawn  and  the  bowels  moved  daily  without  straining. 
If  conditions  be  present  likely  to  induce  subinvolution — such,  for  exam- 
ple, as  pelvic  inflammation  or  laceration  of  the  cervix — they  should 
receive  treatment  at  the  proper  time.  Undue  relaxation  of  the  pelvic 
floor  necessitates  a more  prolonged  rest  in  bed,  the  use  of  astringent 
douches,  and  the  application  of  a pessary  when  the  patient  resumes  the 
upright  position. 

Treatment. — The  first  indication  is  replacement,  which  in  the  first 
and  second  degree  of  descent  is  not  difficult  unless  the  uterus  be  held 
down  by  cicatrices  or  by  a tumor.  Complicating  pelvic  cellulitis  and 
peritonitis  may  render  replacement  dangerous  or  impossible,  and  may  for 
a time  contraindicate  all  direct  treatment.  Replacement  of  the  organs 
from  the  third  degree  of  prolapse  is  accomplished  in  the  inverse  order  of 
their  descent : first,  the  posterior  vaginal  wall,  then  the  uterus,  and  last  the 
anterior  vaginal  wall.  Not  infrequently  the  completely  prolapsed  uterus 
and  pelvic  floor,  hernia-like,  become  strangulated.  Then  taxis  will  usually 
suffice  if  supplemented  by  hot  applications,  elastic  pressure,  anodynes,  and 
the  knee-chest  position.  Should  these  fail  anaesthesia  may  be  required. 

Undue  pressure  from  above  should  if  possible  be  removed.  The 
clothing  should  be  loose,  and  the  weight  of  the  skirts  supported  from  the 
shoulders  either  by  straps  or  preferably  by  buttoning  them  upon  a waist 
made  for  the  purpose.  This  waist  is  a good  substitute  for  the  corset, 
which  under  all  circumstances  and  in  all  its  forms  is  injurious.  Increased 
uterine  weight  from  subinvolution  or  congestion  is  to  be  overcome  by 
appropriate  means.  Enlargement  of  the  uterus  when  due  to  hypertrophy 
or  hyperplasia  is  generally  incurable.  Amputation  of  the  cervix  for 
what  was  formerly  considered  circular  hypertrophy  and  hypertrophic 
elongation  is  now  seldom  or  never  required  for  the  purpose  of  decreasing 
uterine  weight.  Amputation  except  for  malignant  disease  has  given  place 
to  the  operation  of  trachelorraphy.  Tumors  exerting  pressure  above  or 
traction  below  should  if  possible  be  removed.  Regulation  of  the  bowels 
and  general  tonics  are  usually  necessary.  The  knee-chest  position 
assumed  several  times  a day  causes  the  uterus  to  gravitate  toward  the 
diaphragm,  and  thereby  gives  temporary  rest  to  the  overburdened  sup- 
ports. While  in  this  position  the  patient  should  separate  the  labia,  so 
that  the  air  may  rush  in  and  the  vagina  become  expanded.  The  measures 
enumerated  above,  together  with  rigid  care  of  the  diet  and  of  such  other 
hygienic  requirements  as  the  individual  case  may  demand,  are  essential 
as  adjuvants  to  the  more  special  treatment  which  almost  every  case 
requires. 


160 


DISPLACEMENTS  OF  THE  UTERUS. 


In  exceptional  cases  of  sudden  descent,  even  to  the  third  degree, 
replacement  alone  is  sometimes  followed  by  permanent  relief ; but  if  the 
descent  has  been  gradual  it  always  recurs  immediately  after  replacement. 
Measures  are  therefore  required  for  the  maintenance  of  the  uterus  in  its 
normal  location  and  position.  This  indication  is  fulfilled  by  pessaries 
and  by  operations. 

Pessaries. — The  function  of  the  pessary  is  not  only  to  maintain  the 
uterus  on  the  health  level  in  its  normal  location,  but  also,  if  possible, 
in  its  normal  position,  which  requires  the  cervix  to  be  about  one  inch 
from  the  sacrum.  The  cervix  being  thus  placed,  the  organ  cannot  turn 
back  into  retroversion,  because  in  so  doing  the  fundus  would  encoun- 
ter the  sacrum.  The  direction  of  least  resistance  would  then  be  for- 
ward into  the  normal  anterior  position.  The  application  of  the  pessary 
is  then  based  upon  the  general  proposition  that  if  the  cervix  be  normally 
placed  the  body  of  the  uterus  will  in  the  absence  of  complications  take 
care  of  itself.  Since  the  vagina  at  its  upper  extremity  is  attached  to  the 
cervix,  displacement  of  the  latter  is  clearly  impossible  if  the  upper  ex- 
tremity of  the  vagina  be  sustained  in  its  normal  location.  The  pessary 
restores  and  maintains  the  relations  of  the  relaxed  vaginal  walls  by 
crowding  the  posterior  vaginal  cul-de-sac  backward  into  the  hollow  of 
the  sacrum.  It  thereby  also  holds  the  attached  cervix  within  a proper 
distance  of  the  sacrum.  The  Hodge  pessary  or  some  modifications  there- 
of fulfils  this  purpose  in  ordinary  cases  more  satisfactorily  than  any 
other. 

The  curves  of  the  pessary  demand  careful  attention  in  its  application. 
When  the  uterus  is  below  the  normal  level,  the  broad  ligaments  are 
necessarily  rendered  more  tense  than  natural,  and  the  blood-vessels,  more 
especially  the  veins,  which  are  looped  one  upon  the  other,  and  which 
traverse  these  ligaments  to  and  from  the  uterus,  are  made  to  collapse. 
This  causes  venous  congestion  and  consequent  increase  in  weight  of  the 
uterus — a condition  favorable  to  malposition,  uterine  catarrh,  and  patho- 
logical changes  in  structure.  A pessary  which  will  raise  the  uterus  to 
the  health  level  clearly  fulfils  an  indication.  A pessary  which  raises  it 
above  the  health  level  renders  the  broad  ligaments  tense  and  reproduces 
a condition  which  it  was  designed  to  relieve.  Maintenance  of  the  uterus 
upon  the  health  level  depends  largely  upon  the  curves  of  the  pessary. 


The  accompanying  cuts  illustrate  the  shape  and  curve  of  the  Hodge 
pessary  as  modified  by  Emmet  and  Albert  Smith.  Fig.  7 represents  the 
curve  of  Emmet,  and  Fig.  8 that  of  Albert  Smith.  For  convenience 
let  us  characterize  that  curve  which  rests  in  the  posterior  vaginal  cul-de- 
sac  as  the  uterine  curve,  and  that  which  occupies  that  part  of  the  vagina 


DESCENT  OB  PROLAPSE  OF  THE  UTERUS. 


161 


adjacent  to  the  pubis  the  pubic  curve.  The  acuteness  and  length  of  the 
uterine  curve  determine  the  height  to  which  the  pessary  will  lift  the 
uterus.  The  longer  and  more  acute  the  curve,  the  higher  the  uterus  will 
be  lifted,  and  vice  versa.  The  smaller  curve  of  the  Emmet  modification 
will  answer  the  average  indication  more  nearly  than  the  sharper  curve 
of  the  Albert  Smith  modification,  which  may  lift  the  uterus  too  high. 
The  pubic  should  generally  be  proportioned  to  the  uterine  curve;  that  is, 
the  greater  the  uterine,  the  greater  the  pubic  curve.  A pessary  properly 
adjusted  in  all  other  respects  may,  by  pressure  upon  the  urethra  and  neck 
of  the  bladder,  create  vesical  tenesmus  and  urethral  irritatiou.  This  calls 
for  increase  in  the  pubic  curve.  The  pubic  curve  may,  however,  be  so 
great  that  the  lower  part  of  the  pessary  occupies  the  centre  of  the  vulva, 
where  it  may  create  irritation.  For  this  condition  lessening  of  the  pubic 
curve  is  the  remedy.  The  pessary  should  not  be  so  wide  as  to  distend 
the  vagina.  Its  length  should  be  measured  by  the  distance  from  the 
lower  extremity  of  the  symphysis  pubis  to  the  posterior  vaginal  cul-de- 
sac,  less  the  thickness  of  the  finger.  If  properly  adjusted  it  should 
sustain  the  pelvic  floor  in  its  normal  relations  and  the  uterus  in  stable 
equilibrium. 

The  uterus  in  the  first  and  second  degrees  of  descent  is  usually  either 
retroverted  or  retroflexed.  The  reader  is  therefore  referred  to  the 
remarks  on  the  application  of  pessaries  in  the  treatment  of  these  dis- 
placements. 

In  advance  prolapse  dependent  upon  extensive  injuries  to  the  perineum 
and  other  parts  of  the  pelvic  floor,  and  usually  associated  with  extreme 
subinvolution  of  all  the  pelvic  organs,  the  axis  of  the  vagina  is  often 
changed  from  its  forward  oblique  to  the  vertical  direction.  (See  Fig.  3.) 
The  downward  traction  of  the  prolapsing  cystocele  and  rectocele  upon 
the  fornix  of  the  vagina  may  then  be  so  great  that  the  pessary  is  inade- 
quate to  maintain  in  place  the  upper  extremity  of  the  vagina.  The  cervix 
then  moves  forward,  the  corpus  turns  back,  and  the  whole  uterus  easily 
descends  in  a vertical  direction  along  the  prolapsing  walls  of  the  vagina 
to  the  second  or  third  degree  of  prolapse.  In  this  condition  pessaries 
which  disappear  within  the  vagina  are  liable  to  be  forced  out  with  the 
prolapsing  pelvic  floor,  or  if  retained  seldom  maintain  the  uterus  in  posi- 
tion. In  such  cases  the  various  cup  pessaries  which  are  supplied  with 
external  attachments  and  abdominal  belts  are  often  used,  but  they  are 
inadequate,  because  they  either  so  fix  the  uterus  as  to  prevent  its  normal 
movements,  or  they  hold  it  in  such  unstable  equilibrium  that  it  may 
assume  any  one  of  the  various  malpositions,  anterior,  posterior,  or  lateral  ; 
and  they  are  open  to  the  further  serious  objection  of  constantly  reminding 
the  patient  of  their  presence.  As  an  expedient  the  uterus  may  sometimes 
be  held  within  the  pelvis  by  means  of  a large  Albert  Smith  pessary  with 
extreme  uterine  and  pubic  curves.  The  rational  treatment,  however, 
requires  first  an  operation  on  the  anterior  vaginal  wall  to  restore  the 
fornix  of  the  vagina  to  its  normal  place  in  the  hollow  of  the  sacrum,  and 
with  it  the  attached  cervix ; and  second,  an  operation  at  the  vaginal  out- 
let to  bring  the  posterior  wall  in  contact  with  the  anterior,  and  thereby 
to  restore  the  lower  extremity  of  the  vagina  to  its  normal  place  under 
the  pubis. 

Anterior  Elytrorrhaphy. — Numerous  operations  on  the  vaginal 
lrOL.  iv.— 1 1 


162 


DISPLACEMENTS  OF  THE  UTERUS. 


walls  have  been  devised  for  the  purpose  of  narrowing  the  vagina,  and 
thus  preventing  descent  along  the  vaginal  canal,  but  they  are  temporary 
in  their  results,  because,  as  long  as  the  direction  of  the  vagina  remains 
vertical,  its  walls  again  become  dilated  by  the  prolapsing  uterus  and  the 
former  condition  is  re-established.  The  operation  to  be  effective  is  per- 
formed as  follows : A Sims’s  speculum  of  long  blade,  perforated  at  its 
extreme  end,  to  which  the  cervix  has  been  attached  by  a piece  of  silver 
wire,  passing  through  the  perforation  and  the  posterior  lip,  is  intro- 
duced, the  patient  being  in  Sims’s  position.  The  cervix  is  thereby 
drawn  by  the  point  of  the  speculum  far  back  into  the  hollow  of  the 
sacrum.  The  author  finds  this  preferable  to  the  method  described  by 
Emmet,  who  has  the  cervix  held  back  by  a sponge  probang  in  the 
hand  of  an  assistant.  The  space  in  the  anterior  part  of  the  pelvis  is 
now  so  increased  that  the  uterus  readily  falls  forward  into  decided  ante- 
version.  While  the  uterus  is  thus  held  in  position  by  its  attachment  to 
the  blade  of  the  speculum,  the  operator  with 
two  uterine  tenacula  finds  in  the  loose  vagi-  Fig.  10. 

nal  tissue  on  either  side  of  the  cervix  two 
points  which  can  be  brought  together  in 
front  of  the  cervix.  Then  at  each  of  the 
two  lateral  points  a surface  is  denuded 
with  the  curved  scissors  about  one-half 


Fig.  9. 


The  First  Suture  before  Twisting  in  Emmet’s  Operation  for  Folds  on  the  Anterior  Vaginal  Wall 
Procidentia  (Emmet).  formed  after  Twisting  the  First  Su- 

ture (Emmet). 


inch  square,  and  in  front  of  the  cervix  a surface  an  inch  long  by  half  an 
inch  wide  across  the  anterior  vaginal  wall  close  to  the  uterine  attachment. 
A No.  26  silver-wire  suture  is  then  passed,  as  shown  in  Fig.  9,  and  twisted 
as  shown  in  Fig.  10,  so  as  to  secure  the  lateral  denuded  surfaces  in  contact 
with  the  larger  surface  in  front  of  the  cervix. 

Inasmuch  as  the  operation  often  fails  at  the  point  of  the  first  suture, 
the  author  has  usually  introduced  two  or  three  of  this  kind  instead  of 
one.  Two  longitudinal  folds  are  now  formed  on  the  anterior  vaginal 
wall,  which  serve  as  guides  for  denuding  and  turning  in  the  remaining 
redundant  tissue  by  a line  of  sutures,  which  should  extend  forward  along 
the  centre  of  the  vesico-vaginal  wall  until  the  folds  are  lost  in  the  vaginal 
surface  near  the  neck  of  the  bladder.  Sometimes  the  redundant  tissue 
about  the  urethra  cannot  be  disposed  of  by  turning  it  in  from  side  to 
side.  Then  it  is  desirable  to  make  a crescentic  denudation  across  the 
lower  portion  of  the  vagina,  its  concavity  being  on  the  uterine  side,  and 


DESCENT  OB  PROLAPSE  OF  THE  UTERUS. 


163 


to  unite  the  margins  below  to  those  above  by  means  of  a curved  line  of 
sutures.  The  completed  operation  is  shown  in  Fig.  11. 

The  after-treatment  requires  the  self-retaining  Sims’s  sigmoid  catheter 
in  the  urethra  for  a week  or  frequent  catheterization,  absolute  rest  in  bed, 
hot-water  vaginal  douches,  regulation  of  the  bowels,  and  the  removal  of 


Fig.  11. 


the  sutures  on  the  twelfth  day.  After  the  completion  of  the  operation 
the  cervix  is  maintained  near  the  hollow  of  the  sacrum,  and  the  organ 
remains  normally  anteverted  and  anteflexed,  making  an  acute  angle  with 
the  vesico- vaginal  wall,  which  has  now  been  restored  to  its  normal  direc- 
tion and  length.  Unfortunately,  it  is  not  unusual  to  abandon  the  patient 
after  this  operation,  in  the  vain  hope  that  the  uterus  and  anterior  vaginal 
wall  will  maintain  their  normal  relations  without  the  support  of  the 
perineum  and  posterior  vaginal  wall.  This  is  a great  mistake,  because 
the  cystocele  and  procidentia  almost  always  completely  reappear  within 
a few  months.  Anterior  elytrorrhaphy,  therefore,  is  simply  one  of  the 
steps  in  the  treatment. 

Perineorrhaphy. — This  is  the  name  usually  applied  to  the  repair 
of  the  ruptured  perineum,  but  the  scope  of  the  operation  has  been  extended 
to  include  also  the  surgical  treatment  of  rectocele  and  relaxation  of  the 
posterior  vaginal  wall.  The  most  scientific  operation  yet  devised  is  the 
one  proposed  by  Emmet,1  which  is  performed  as  follows : The  patient 
being  etherized  and  in  the  lithotomy  position,  the  operator  seizes  with  a 
tenaculum  the  crest  of  the  rectocele  or  posterior  vaginal  wall  at  a point 
which  can  be  drawn  forward  without  undue  traction — point  a.  With 
another  tenaculum  the  lowest  caruncle  or  vestige  of  the  hymen  (point  6), 

1 Trans.  Am.  Gynaecological  Society , 1883  ; Principles  and  Practice  of  Gynecology , 3d  ed. 


164 


DISPLACEMENTS  OF  THE  UTERUS. 


and  with  another  the  posterior  commissure  of  the  vulva  (point  c),  are 
hooked  up.  The  triangle  included  between  these  points  defines  one-half 
of  the  surface  to  be  denuded.  The  three  tenacula  are  now  placed  in  the 
hands  of  assistants,  the  sides  of  the  triangle  are  made  tense  by  traction, 
and  the  included  surface  denuded.  The  tenaculum  at  c is  then  removed, 
and  the  middle  point  of  the  line  a 6 is  caught  and  drawn  toward  the 
interior  of  the  vagina  in  the  direction  of  the  vaginal  sulcus  on  that  side, 
and  the  sutures  are  introduced,  as  in  Fig.  13.  The  same  thing  is  then 
repeated  on  the  other  side,  and  the  sutures  are  all  tightened,  forming  a 
line  of  union  running  back  into  each  sulcus,  as  shown  in  Fig.  14. 

The  essential  part  of  the  operation  inside  the  vagina  almost  always 
succeeds,  but  the  external  part  of  the  rupture  at  the  posterior  commissure 


Fig.  12. 


a is  at  the  crest  oi  the  rectocele;  b at  the  caruncle  just  within  the  labium  ; and  c at  the  posterior  com- 
missure. The  cut  represents  that  half  of  the  surface  to  be  denuded  which  is  on  the  operator’s  right. 
The  dotted  lines  represent  the  other  half,  on  the  left. 


often  fails  to  unite;  furthermore,  the  operation  as  described  by  Emmet  does 
not  overcome  the  patulous  condition  of  the  introitus  vaginfe  in  case  of  great 
relaxation  of  the  vagina.  The  author  has  sought  to  obviate  the  first  of 
these  difficulties  by  the  use  of  deep  silver  sutures  instead  of  the  superficial 
ones  described  by  Emmet.  They  should  be  introduced  before  tightening 
the  vaginal  sutures,  and  should  be  passed  far  around  in  the  posterior 
vaginal  wall,  their  points  of  entrance  and  exit  being  the  same  as  for  the 
three  lower  unsecured  superficial  external  sutures  in  Fig.  14.  The  second 
difficulty  may  be  overcome  by  further  denuding  a triangular  surface 
in  the  vaginal  sulcus  on  each  side,  the  base  of  the  triangle  corresponding 


RETROVERSION. 


165 


to  the  line  a b,  Fig.  12,  and  its  apex  being  in  the  vaginal  sulcus  at  a dis- 
tance corresponding  to  the  degree  of  relaxation.  This  increases  the  lengtn 
of  the  lines  of  union  running  into  the  sulci  represented  by  d 6 and  ef, 
Fig.  14.  In  the  vaginal  portion  of  the  wound  silk  or  catgut  is  prefer- 
able to  silver,  the  latter  being  difficult  to  remove. 

Fig.  13.  Fig.  14. 


Fig.  13.  The  Sutures  in  Place.  When  secured  they  will  unite  ad  with  b d , and  lift  the  perineum  up  in 
contact  with  the  anterior  vaginal  wall. 

Fig.  14.  All  the  Vaginal  Sutures  Twisted.  One  suture,  including  the  crest  of  the  rcctocele  and  the  labium 
majus  on  either  side,  and  three  superficial  external  sutures,  are  yet  to  be  secured.  The  lines  a d and 
d b,  Fig.  13,  have  been  brought  into  coincidence  by  means  of  the  sutures,  and  now  form  the  line  of  union 
db.  The  tissues  between  the  lines  ac  and  cb,  Fig.  13,  have  been  so  lifted  up  and  are  so  held  under 
the  line  of  union  db  that  the  line  c 6,  Fig.  13,  has  been  reduced  to  c b , Fig.  14,  which  makes  the  exter- 
nal portion  of  the  wound  insignificant  in  extent. 

Emmet  is  entitled  to  great  credit  for  having  given  to  the  profession  an 
operation  which  brings  the  posterior  vaginal  walls  up  against  the  anterior 
more  perfectly  than  any  other,  and  which,  being  mostly  inside  of  the 
vagina,  is  therefore  followed  by  very  little  of  the  pain  during  convales- 
cence which  formerly  rendered  perineorrhaphy  one  of  the  most  trying 
operations  in  gynecology.  The  operation  furthermore  has  demonstrated 
the  former  teachings  relative  to  the  direction  of  perineal  rupture 1 and  the 
tissues  involved  to  be  incorrect,  or  at  least  inadequate. 


Retroversion. 

Retroversion  is  that  position  of  the  uterus  in  which  the  fundus  is  pos- 
terior to  the  axis  of  the  pelvic  inlet.  If  the  cervix  be  in  its  normal  place 
near  the  sacrum,  retroversion  is  scarcely  possible,  because  it  is  prevented 
by  the  proximity  of  the  over-arching  sacrum.  (See  Fig.  2.)  The  first 
degree  of  prolapse  must  therefore  precede  any  considerable  backward 
turning  of  the  uterus.  When  the  cervix  has  been  displaced  downward 

1 At  the  meeting  of  the  American  Medical  Association  in  June,  1883,  the  author  pre- 
sented a paper  describing  the  transverse  laceration  of  the  perineum  and  its  operative 
treatment,  which  was  published  with  illustrations  in  the  transactions  by  the  journal  of 
the  Association,  Dec.  22,  1883.  This  communication  referred  only  to  the  recent  rupture 
and  the  immediate  operation. 


166 


DISPLACEMENTS  OF  THE  UTERUS. 


and  forward  so  far  that  its  distance  from  the  sacrum  is  equal  to  or  greatei 
than  the  length  of  the  uterus,  retroversion  to  any  extent  becomes  pos- 
sible. (See  Figs.  3 and  16.) 

Etiology  and  History. — From  the  above  it  follows  that  the 
causes  of  commencing  retroversion  must  be  identical  with  the  causes 
of  the  first  degree  of  prolapse.  After  the  puerperium  the  relaxation  of 
the  supports  and  the  weight  of  the  organ  may  persist,  and  spontaneous 
replacement  may  be  prevented  by  the  pressure  and  weight  of  the  intes- 
tines upon  the  anterior  surface.  Every  act  of  defecation  forces  the  cervix 
forward  and  downward,  and  the  uterus,  being  in  the  axis  of  the  vagina, 
and  having  therefore  little  support  below,  must  depend  upon  the  sub- 
involuted peritoneal  suspensory  ligaments  and  pelvic  fascia,  which  are 
inadequate.  This  condition  is  very  often  induced  by  abortions,  with 
resulting  increased  weight  and  relaxation  of  the  vaginal  walls.  Local 
peritonitis  and  cellulitis  may  permanently  fix  the  corpus  in  its  retro- 
verted  position  by  cicatricial  bands  and  adhesions. 

Symptoms  and  Course. — The  displacement  and  its  complications 
usually  cause  bearing-down  sensations,  a feeling  of  heaviness  in  the 
pelvis,  exhaustion  upon  walking  and  standing,  especially  the  latter,  and 
constipation.  After  the  puerperium  the  extreme  engorgement  of  the 
pelvic  organs  often  produces  uterine  hemorrhage,  which  should  not  be 
confounded  with  the  returning  menstruation.  Especially  after  abortion 
the  hemorrhage  often  persists  for  a long  time  unless  cured  by  treatment. 
Gradual  or  sudden  replacement  may  occur  spontaneously,  or  the  causes 
may  continue  active,  and  even  be  enforced  by  cystocele  and  rectocele. 
The  displacement  may  also  be  complicated  by  disease  and  displacement 
of  the  ovaries.  Organic  disease  of  the  uterine  walls  may  induce  a super- 
added  retroflexion.  The  heavy  organ  may  descend  along  the  relaxed 
subinvoluted  vaginal  walls  even  to  complete  procidentia. 

Diagnosis  and  Prognosis. — The  symptoms  outlined  in  the  preceding 
paragraph  indicate  the  probability  of  displacement,  but  the  diagnosis 
depends  upon  direct  examination  of  the  uterus.  Conjoined  manipulation 
and  the  probe  will  usually  show  the  retroverted  organ  with  the  cervix 
displaced  toward  the  pubes  and  with  the  corpus  in  the  hollow  of  the 
sacrum.  The  introduction  of  the  probe  is  contraindicated  by  cellulitis 
and  peritonitis.  In  certain  cases  of  anteflexion,  as  represented  in  Fig. 
23,  the  cervix  is  bent  forward  in  the  vaginal  axis  as  in  retroversion. 
The  condition  is  in  reality  one  of  retroversion  of  the  cervix  with  high 
anteflexion  of  the  corpus,  which  may  usually  be  detected  by  careful  con- 
joined examination.  The  prognosis  with  treatment  is  generally  favor- 
able both  for  speedy  relief  and  ultimate  recovery. 

Treatment. — As  in  descent,  the  treatment  consists  in  removing  cellu- 
litis, peritonitis,  and  other  complications,  in  the  use  of  pessaries,  and  in 
operations  on  the  anterior  and  posterior  vaginal  walls  if  needed.  Inas- 
much as  the  treatment  corresponds  to  that  of  retroflexion,  it  will  be  pre- 
sented under  that  subject. 


Retroflexion. 

Etiology  and  Pathology. — Retroflexion  is  that  displacement  iD 
which  the  organ  is  bent  backward  upon  itself.  It  usually  results  from, 


RETROFLEXION 


167 


and  is  associated  with,  retroversion,  but  for  convenience  the  double  dis- 
placement will  be  termed  retroflexion.  It  may  be  caused  by  the  great 
weight  of  the  corpus,  the  soft  flexible  state  of  the  uterine  walls  during 
and  after  involution,  intra-abdominal  forces,  downward  pressure  during 
defecation,  tight  clothing,  and  not  commonly  by  the  obstetric  bandage. 

The  ovaries,  unless  fixed  elsewhere  by  adhesions,  are  displaced  with, 
and  held  down  on  either  side  of,  the  corpus,  sometimes  enlarged  from 
inflammation,  often  adherent,  and  always  extremely  sensitive.  Chronic 
metritis,  cellulitis,  and  peritonitis,  with  adhesions  more  or  less  firm,  are 
usually  present,  and  not  infrequently  as  the  result  of  gonorrhoea,  abor- 
tion, or  injudicious  treatment.  Peritoneal  adhesions  between  the  corpus 


Fig.  15. 


Extreme  Retroflexion,  with  Hypertrophy  of  the  CorpuSj  which  impinges  upon  the  rectum  and  com- 
presses the  recto-vaginal  wall. 

and  the  cul-de-sac  of  Douglas  sometimes  make  replacement  impossible. 
In  rare  cases  the  displacement  is  congenital. 

Symptoms  and  Course. — Among  the  most  pronounced  symptoms  are 
profuse  uterine  catarrh,  menstrual  disorders,  sterility,  abortion,  weakness, 
pain  in  the  back,  painful  defecation,  rectal  tenesmus,  the  symptoms  of 
pelvic  inflammation,  neurasthenia,  and  other  nervous  symptoms.  The 
uterine  catarrh  is  due  to  an  effort  on  the  part  of  the  engorged  pelvic 
organs  to  relieve  themselves  by  an  exaggerated  secretion  of  mucus  from 
the  uterus,  which  upon  being  increased  in  quantity  becomes  vitiated  in 
quality,  and  therefore  pathological.  Menorrhagia  and  abortion  may  also 
result  from  congestion.  Dysmenorrhoea  and  sterility  result  from  the  gen- 


168 


DISPLACEMENTS  OF  THE  UTERUS. 


eral  anaemic  condition  and  from  the  inflammatory  complications,  and 
from  the  obstruction  in  the  uterine  canal  or  in  the  blood-vessels  at  the 
angle  of  flexure.  (See  Pathology  of  Anteflexion.)  The  rectal  symp- 
toms are  caused  by  the  pressure  of  the  corpus  uteri  upon  the  rectum, 
which  gives  the  sensation  to  the  patient  of  an  overloaded  bowel. 

Should  pregnancy  occur,  the  rapid  growth  of  the  uterus  may  induce 
spontaneous  reposition  at  about  the  fourth  month,  when  the  fundus  rises 
out  of  the  pelvis,  but  if  the  corpus  be  incarcerated  under  the  sacral 
promontory  from  adhesions  or  from  any  other  cause,  the  uterus  will, 
unless  manually  replaced,  relieve  itself  by  abortion. 

Abdominal  pains,  nervous  dyspepsia,  and  neuralgia  in  distant  parts  of 
the  body  are  often  present ; indeed,  the  nervous  symptoms  may  be  of  the 
most  exaggerated  character,  and  may  comprise  all  that  is  implied  by  the 
word  hysteria  in  its  most  comprehensive  signification. 

Diagnosis. — Digital  touch  discloses  the  cervix  low  in  the  pelvis,  and 
the  fundus  uteri  is  felt  through  the  posterior  vaginal  wall  in  the  cul-de- 
sac  of  Douglas.  Conjoined  manipulation  with  the  index  finger  of  the 
left  hand,  first  in  the  vagina  and  then  in  the  rectum,  and  the  right  hand 
over  the  hypogastric  region,  will  show  the  size,  form,  consistency,  and  loca- 
tion of  the  uterus,  the  degree  of  the  flexure,  and  the  difficulty  of  replace- 
ment. An  inflammatory  exudate  or  hsematocele,  posterior  to  the  uterus, 
or  a fibroid  in  the  posterior  uterine  wall,  may  be  mistaken  for  the  retro- 
flexed  corpus.  The  probe  will  always  verify  the  diagnosis,  but  if  there 
be  great  tenderness  with  fixation  in  the  cul-de-sac  of  Douglas,  treatment 
should  be  directed  against  the  inflamed  condition,  and  the  final  diagnosis 
made  by  repeated  examinations  or  after  the  disappearance  of  the  inflam- 
mation. Great  and  lasting  injury  is  often  done  in  the  attempt  to  com- 
plete the  diagnosis  at  the  first  examination.  The  presence  of  a fibroid 
in  the  posterior  uterine  wall  with  post-uterine  inflammation  is  a serious 
complication  both  in  diagnosis  and  treatment.  If  the  rectum  be  over- 
loaded with  fecal  matter,  the  diagnosis  should  be  deferred.  The  displace- 
ment is  distinguished  from  the  presence  of  an  ovary  or  small  ovarian 
tumor  in  the  pouch  of  Douglas  by  careful  bimanual  examination  and  by 
the  probe. 

Treatment  of  Retroversion  and  Retroflexion. — The  objects 
of  treatment  are  replacement  and  retention  of  the  uterus.  The  obstacles 
to  replacement  are  cellulitis,  peritonitis,  and  fixation  of  the  uterus,  and 
these  complications  often  require  weeks,  and  in  severe  cases  months,  of 
treatment  preparatory  to  replacement.  Some  of  the  general  therapeutic 
suggestions  under  the  subject  of  descent  are  also  applicable  to  the  retro- 
positions.  Rest,  massage,  careful  regulation  of  the  bowels,  feeding,  and 
general  tonics  are  essential.  For  the  inflammation  small  blisters  over  the 
inguinal  regions  frequently  repeated,  and  the  daily  application  of  the  cot- 
ton and  glycerin  plug  to  the  cervix,  and  dry  cupping  over  the  sacrum, 
are  most  efficacious.  The  glycerin  may  be  combined  with  alum,  tannin, 
chloral  hydrate,  or  iodoform.  Thymoline  in  small  quantities  partially 
destroys  the  disagreeable  iodoform  odor.  The  most  useful  and  essential 
topical  application  is  the  hot-water  vaginal  douche,  but  its  use  will  be 
followed  by  failure  and  disappointment  if  it  be  applied  in  the  ordinary 
way.  The  following  is  quoted  from  a paper  by  the  author  whicli  was 
published  in  the  Chicago  Medical  Gazette , Jan.  1,  1880: 


RETROFLEXION. 


1(59 


“ Ordinary  Method  of  Application. 

“ I.  Ordinarily,  the  douche  is  applied 
with  the  patient  in  the  sitting  posture, 
so  that  the  injected  water  cannot  fill  the 
vagina  and  bathe  the  cervix  uteri,  but, 
on  the  contrary,  returns  along  the  tube 
of  the  syringe  as  fast  as  it  flows  in. 

“ II.  The  patient  is  seldom  impressed 
with  the  importance  of  regularity  in  its 
administration. 

“ III.  The  temperature  is  ordinarily 
not  specified  or  heeded. 


“ IV.  Ordinarily,  the  patient  aban- 
dons its  use  after  a short  time.” 


“ Proper  Method  of  Application. 

“ I.  It  should  invariably  be  given  with 
the  patient  lying  on  the  back,  with  the 
shoulders  low,  the  knees  drawn  up,  and 
the  hips  elevated  on  a bed-pan,  so  that 
the  outlet  of  the  vagina  may  be  above 
every  other  part  of  it.  Then  the  vagina 
will  be  kept  continually  overflowing 
while  the  douche  is  being  given. 

“II.  It  should  be  given  at  least  twice 
every  day,  morning  and  evening,  and 
generally  the  length  of  each  application 
should  not  be  less  than  twenty  minutes. 

“ III.  The  temperature  should  be  as 
high  as  the  patient  can  endure  without 
distress.  It  may  be  increased  from  day 
to  day,  from  100°  or  105°  to  115°  or  120° 
Fahr. 

“ IY.  Its  use,  in  the  majority  of  cases, 
should  be  continued  for  months  at  least, 
and  sometimes  for  two  or  three  years. 
Perseverance  is  of  prime  importance.” 


“ A satisfactory  substitute  for  the  bed-pan  may  be  made  as  follows : 
Place  two  chairs  at  the  side  of  an  ordinary  bed  with  space  enough 
between  them  to  admit  a bucket ; place  a large  pillow  at  the  extreme 
side  of  the  bed  nearest  the  chairs ; spread  an  ordinary  rubber  sheet  over 
the  pillow,  so  that  one  end  of  the  sheet  may  fall  into  the  bucket  below  in 
the  form  of  a trough.  The  douche  may  then  be  given  with  the  patient’s 
hips  drawn  well  out  over  the  edge  of  the  bed  and  resting  on  the  pillow, 
and  with  one  foot  on  each  chair ; the  water  will  then  find  its  way  along 
the  rubber  trough  into  the  bucket  below.”  The  Davidson  syringe,  which 
has  an  interrupted  current,  is  preferable  to  any  of  the  fountain  syringes. 

As  the  tenderness  disappears  the  cotton  plugs  may  be  increased  in 
quantity,  and  thereby  made  to  serve  as  temporary  support  for  the  uterus 
until  a more  permanent  pessary  can  be  substituted.  The  sluggish  circu- 
lation in  the  pelvis  and  torpid  condition  of  the  bowels  may  be  much 
relieved  by  the  daily  application  of  the  wet  pack.  A small  flannel  sheet 
folded  lengthwise  to  the  width  of  two  feet,  dipped  in  very  hot  water,  and 
dried  by  passing  it  through  a wringer,  is  wound  about  the  hips  and  cov- 
ered by  another  dry  one.  At  the  end  of  a half  hour,  during  which  time 
the  patient  maintains  the  recumbent  position,  the  sheets  are  removed. 
When  the  tenderness  has  been  sufficiently  reduced,  gentle  attempts  at 
leplacement  may  be  made  every  day  or  two  by  conjoined  manipulation. 
The  patient’s  tolerance  of  manipulation  may  thus  be  observed  and  the 
way  prepared  for  complete  replacement  and  permanent  retention  after  the 
subsidence  of  the  inflammation. 

In  retroversion  and  retroflexion  always  replace  the  uterus  before  adjust- 
ing the  pessary,  otherwise  the  instrument  will  press  upon  the  sensitive 
uterus,  when  one  of  three  unfortunate  results  must  occur : (1)  The  pes- 
sary may  not  be  tolerated  on  account  of  pain  ; (2)  the  pessary  may  be 
forced  down  by  pressure  from  above  so  near  to  the  vulva  that  it  will  fail 
to  do  the  least  good ; (3)  the  uterus,  finding  it  impossible  to  hold  its 
position  against  the  pessary,  instead  of  taking  its  proper  position  will 
often  be  bent  over  it  in  exaggerated  retroflexion,  with  the  cervix  between 


170 


DISPLACEMENTS  OF  THE  UTERUS. 


the  pessary  and  the  pubes  and  the  body  between  the  pessary  and  the 
sacrum,  or  the  whole  organ  may  slip  off  to  one  side  of  the  instrument 
into  a malposition  more  serious  than  the  one  for  which  relief  is  sought. 
The  safest  and  most  effective  method  of  replacement  is  by  conjoined 
manipulation,  as  represented  in  Figs.  16  and  17.  The  dotted  lines  in 
the  former  indicate  the  gradual  elevation  of  the  corpus  out  of  the  hollow 
of  the  sacrum  to  the  pelvic  brim,  where  it  may  be  anteverted  by  the 
fingers  of  the  right  hand  pressed  well  down  behind  its  posterior  wall. 
During  the  process  of  anteversion  the  index  finger  of  the  left  hand  in 
the  anterior  fornix  of  the  vagina  presses  the  cervix  back  to  its  place  in 
the  hollow  of  the  sacrum,  as  in  Fig.  17.  Efficient  reposition  of  the 
uterus  is  very  often  impossible  without  anaesthesia. 

Fio.  16. 


Comweuciug  Reposition  of  the  Retroverted  or  Retrofiexed  Uterus  by  Conjoined  Manipulation  (modilied 

from  Schultze). 


The  replacement  is  not  usually  accomplished  by  drawing  the  fundus 
forward  and  pushing  the  cervix  back  directly  in  the  median  line.  In 
most  cases  the  fundus  sweeps  around  the  arc  of  a circle  on  the  left  side 
of  the  pelvis,  and  the  cervix  on  the  right.  This  is  owing  to  the  greater 
frequency  of  cellulitis  on  the  left  side,  and  consequent  shortening  of  the 
left  broad  ligament.  After  replacement  the  organ  is  to  be  held  in  posi- 
tion by  a suitable  pessary. 

Bimanual  replacement  has  two  great  advantages  over  the  more  familiar 
methods  of  the  sound  or  repositor : first,  it  is  more  effective  and  more 


RETROFLEXION. 


171 


permanent ; second,  the  lever  action  of  the  sound  or  repositor,  by  which 
the  operator  may  unwittingly  use  an  undue  and  dangerous  amount  of 
force,  is  avoided  in  the  use  of  the  hands,  through  which  the  operation 
is  not  only  constantly  under  his  control,  but  also  within  his  appre- 
ciation. 

Fig.  17. 


Completed  Reposition  of  the  Retroverted  or  Retroflexed  Uterus  by  Conjoined  Manipulation  (modified 

from  Schultze). 


Inasmuch  as  the  pessary  fulfils  its  indications  by  sustaining  the  pelvic 
floor,  and  thereby  holding  the  cervix  in  the  hollow  of  the  sacrum,  the 
same  general  principles,  and  in  fact  the  same  pessaries,  which  are  applic- 
able to  prolapse  apply  also  to  retroversion  and  retroflexion.  Indeed,  the 
first  step  in  the  genesis  of  the  retro-positions  has  been  shown  to  be  prolapse. 
The  student  is  therefore  referred  to  the  general  remarks  on  the  adjust- 
ment of  pessaries  for  prolapse. 

The  operations  of  elytrorraphy  and  perineorraphy,  especially  the  latter, 
already  described  in  the  treatment  of  descent,  are  often  of  the  utmost 
importance  in  the  treatment  of  the  posterior  displacements,  and  should 
therefore  be  carefully  studied  in  this  connection. 

In  the  adjustment  of  the  pessary  it  is  desirable,  if  possible,  to  avoid  direct 
pressure  upon  any  part  of  the  uterus.  Pessaries  designed  to  prop  up  the 
body  of  the  uterus  by  pressure  upon  the  posterior  wall  to  correct  the 
posterior  malpositions,  and  upon  the  anterior  wall  to  correct  the  anterior 
malpositions,  are  very  liable  to  induce  metritis  and  perimetritis,  and  are 
therefore  generally  unsafe.  In  certain  cases,  however,  the  vaginal  walls, 


172 


DISPLACEMENTS  OF  THE  UTERUS . 


especially  the  posterior,  may  be  so  relaxed  from  subinvolution  and  other 
causes  that  the  instrument,  though  very  long,  fails  to  maintain  the  cervix 
in  its  normal  place.  Under  such  conditions  a pessary  may  be  required 
to  act  directly  upon  the  uterus.  The  Schultze’s  sleigh  pessary  repre- 
sented in  Fig.  19  fulfils  this  indication.  Schultze’s  figure-of-eight  pes- 
sary, or  a long  Albert  Smith  pessary  with  its  uterine  curve  made  so 
extreme  as  to  bring  the  upper  part  of  the  instrument  in  front  of  the 
cervix  instead  of  behind,  answers  the  same  purpose. 


Fig.  18. 


Showing  the  Pelvic  Organs  sustained  by  the  Emmet  Pessary  after  reposition  of  the  prolapsed,  retro- 

verted  or  retrod  exed  uterus. 

Thomas’s  retroflexion  pessary,  with  its  bulbous  upper  extremity,  is  a 
long,  narrow  instrument  of  extreme  uterine  curve.  It  lifts  the  uterus 
very  high,  and  is  specially  applicable  in  cases  of  great  relaxation  of  the 
pelvic  floor  and  of  complicating  prolapse  of  the  ovaries  (Fig.  21).  The 
bulbous  portion  is  sometimes  made  of  soft  rubber. 

A properly-adjusted  pessary  gives  to  the  patient  no  consciousness  of 
its  presence.  If  the  instrument  cause  pain  it  should  be  removed  and 
search  made  for  the  tender  places ; it  should  then,  if  possible,  be  re- 
moulded into  such  shape  that  it  will  not  exert  pressure  upon  them. 
Often  a slight  indentation  at  some  point  will  enable  the  patient  to  wear 
it  with  comfort. 

Sometimes  when  the  corpus  has  been  firmly  bound  back  by  peritoneal 
adhesions  they  may  be  broken  up  by  very  forcible  conjoined  manipulation 
under  ether,  but  the  operation  is  dangerous,  and  should  therefore  be  under- 


RETROFLEXION. 


173 


taken  only  by  an  expert  operator.  In  place  of  this  operation  Lawson 
Tait  has  proposed  to  open  the  abdomen,  break  the  adhesions,  and  stitch 
the  fundus  uteri  to  the  abdominal  wound.  This  operation  in  the  hands 
of  such  an  operator  as  Tait  is  probably  not  more  dangerous  than  breaking 
up  firm  adhesions  by  forcible  conjoined  manipulation. 

In  certain  cases  in  which  replacement  is  impracticable  or  impossible  on 
account  of  inflammation  or  adhesions  a soft  rubber  ring  may  be  inserted, 
and  will  often  give  decided  relief  by  lifting  the  uterus  and  pelvic  floor 
nearer  to  the  health  level.  In  the  treatment  of  all  displacements  coition 


Fig.  19. 


Schultze’s  Sleigh  Pessary  iu  place,  as  adjusted  for  prolapse,  retroversion,  or  retroflexion  with  great 
relaxation  of  the  vaginal  walls  (after  Schultze). 

should  be  forbidden  or  permitted  only  with  great  moderation,  and  the 
pessary  should  be  kept  clean  by  copious  daily  applications  of  the  vaginal 
douche.  Every  three  or  four  weeks  the  instrument  should  be  removed 
and  the  pelvic  organs  carefully  examined. 

It  should  be  urged  that  no  man  can  safely  apply  the  pessary  until  he 
has  fully  appreciated  its  indications  and  contraindications.  Few  prac- 
titioners possess  naturally  the  mechanical  skill  necessary  to  its  proper 
adjustment.  Of  this  thousands  of  unfortunate  women  bear  witness. 
Its  dangers  in  inefficient  hands  are  in  striking  contrast  with  its  useful- 
ness when  judiciously  employed. 

Many  cases  of  displacement,  both  anterior  and  posterior,  are  so  com- 
plicated by  prolapsed  and  adherent  ovaries,  by  advanced  disease  of  the 
ovaries  and  Fallopian  tubes,  and  by  peritoneal  adhesions,  that  not  only 


174 


DISPLACEMENTS  OF  THE  UTERUS. 


replacement,  but  even  palliation,  is  impossible;  then,  as  a final  resort, 
the  activity  of  the  pelvic  organs,  both  physiologically  and  pathologically, 
may  be  put  at  rest  by  the  removal  of  the  ovaries  and  Fallopian  tubes. 

William  Alexander  of  Liverpool  has  devised  an  ingenious  operation 
of  shortening  the  round  ligaments  for  the  radical  cure  of  descent  and 


Fig.  20. 


Front  View  of  Schultze’s  Figure-of 
Eight  Pessary.  The  upper  open- 
ing is  intended  to  hold  the  cervix. 
This  pessary  has  the  uterine  and 
pubic  curves,  as  in  Figs.  7 and  8. 


Fig.  21. 


Thomas’s  Retroflexion  Pessary. 


of  the  posterior  displacements.  He  reports  twenty-two  cases  of  the 
operation  in  his  own  practice  and  several  more  in  the  practice  of  other 
surgeons,  with  almost  uniform  success  in  completely  curing  the  dis- 
placements. The  operation,  although  new,  gives  promise  of  a brilliant 
and  successful  future. 


Lateral  Versions  and  Flexions. 

The  lateral  malpositions  which  often  complicate  retroversion  and 
retroflexion  are  usually  the  result  of  inflammation  in  a broad  ligament 
or  in  the  uterus  itself,  or  in  both.  Their  treatment  is  that  of  the  causa- 
tive inflammation,  and  follows  the  general  principles  which  have  been 
laid  down  for  the  treatment  of  other  versions  and  flexions. 


Pathological  Anteversion. 

Sometimes  the  physiological  angle  of  flexure  becomes  obliterated  in 
consequence  of  chronic  metritis,  resulting  in  permanent  straightening  of 
the  uterus,  and  the  cervix  becomes  elevated  and  fixed  above,  or  the  corpus 
depressed  and  fixed  below,  the  normal  level.  This  constitutes  pathologi- 
cal anteversion  (Fig.  22). 

Etiology.—  The  exaggerated  anteversion  of  early  pregnancy  is  phys- 
iological, the  exaggerated  anteversion  of  the  uterus  in  chronic  metritis  is 
pathological.  Elevation  of  the  cervix  and  depression  of  the  corpus  may 
be  induced  by  peritoneal  adhesions.  Increased  weight  from  a mural 
fibroid  may  also  depress  the  corpus. 


PATHOLOGICAL  AETEVERS10E. 


175 


The  symptoms  are  due  to  the  pelvic  inflammations  already  mentioned 
and  other  complications.  The  increased  weight  of  the  uterus,  which  is 
usually  hypertrophied  from  metritis,  generally  causes  a dragging  sensa- 
tion, especially  if  the  organ  be  also  prolapsed.  The  enlarged  corpus 
occupying  the  territory  of  the  bladder  often  induces  persistent  vesical 
irritation  or  even  cystitis.  Menorrhagia,  when  present,  is  the  result  of 
the  metritis  or  a fibroid  rather  than  of  the  displacement  per  se. 

Diagnosis  and  Prognosis. — The  displacement  is  recognized  by  digital 
touch,  which  discloses  the  anterior  wail  of  the  uterus  parallel  to  the 
anterior  wall  of  the  vagina,  with  the  fundus  close  to  the  symphysis  and 
the  cervix  elevated.  Conjoined  examination  will  show  the  size,  shape, 


Fig.  22. 


hardness,  and  degree  of  fixation.  Exaggerated  anteversiou  of  the  healthy 
uterus  is  not  necessarily  pathological  in  its  results.  This  is  illustrated  by 
the  anteversion  of  early  pregnancy.  The  prognosis  is  therefore  good  if 
the  causes  can  be  removed. 

Treatment. — Inasmuch  as  exaggerated  anteversion  is  the  position 
taken  by  the  uterus  in  chronic  metritis,  it  follows  that  the  treatment  is 
often  that  of  chronic  metritis.  For  the  treatment  of  metritis,  perimetritis, 
fibroids,  menorrhagia,  etc.  the  reader  is  referred  to  the  special  literature 
of  tJhose  subjects.  Irritable  bladder,  which  is  often  a mechanical  result 
of  the  displacement  and  enlargement,  may  sometimes  be  relieved  by  means 
of  an  Albert  Smith  or  Hodge  pessary,  which  lifts  the  organ  to  a higher 
level  away  from  the  bladder.  In  thus  elevating  the  uterus  the  ante- 


176 


DISPLACEMENTS  OE  THE  UTERUS. 


version  may  be  rather  increased  than  diminished,  which  proves  that  the 
symptoms  were  dependent  not  upon  the  anteposition,  but  rather  upon 
descent  and  antelocation.  Should  the  parts  be  too  sensitive  to  tolerate 
the  hard-rubber  pessary  or  a flexible  rubber  ring,  the  daily  application 
of  medicated  pledgets  of  cotton  will  give  support  to  the  uterus  and 
decrease  the  tenderness  until  the  more  permanent  instrument  can  be 
worn.  The  numerous  ante  version  pessaries  designed  to  elevate  the 
corpus  by  direct  pressure  on  the  anterior  wall  of  the  uterus  generally 
irritate  the  organ,  and  thereby  aggravate  the  inflammatory  complications. 
They  are  therefore  to  be  used  with  extreme  caution. 


Pathological  Anteflexion. 

Definition. — The  normal  forward  bending  of  the  corpus  upon  the 
cervix  uteri  when  the  bladder  is  empty  makes  an  angle  of  which  the 
approximate  physiological  limits  are  between  45°  and  90°  : the  flexure 
would  generally  be  pathological  if  less  than  45°  or  more  than  90°. 
Furthermore,  if  the  flexure,  whether  it  be  normal  or  abnormal  in  extent, 


Fig.  23. 


Congenital  Anteflexion.  Both  cervix  and  body  are  flexed  forward. 


does  not  disappear  upon  filling  the  bladder,  but  remains  constant  undei 
all  conditions,  the  rigidity  makes  the  flexure  pathological.  Anteflexion 
is  therefore  pathological  if  the  mobility  at  the  angle  of  flexure  is  increased 
nr  diminished  or  absent. 


PATHOLOGICAL  ANTEFLEXION. 


177 


Etiology  and  Pathology. — Anteflexion  may  be  congenital  or 
acquired.  By  congenital  is  meant  not  defective  foetal  development,  but 
failure  of  the  immature  child  uterus  to  develop  at  puberty,  a failure 
which  usually  pertains  alike  to  the  uterus,  Fallopian  tubes,  ovaries,  and 
vagina.  In  congenital  anteflexion  the  uterus  is  bent  upon  itself  almost 
double,  the  body  and  cervix  both  pointing  in  the  direction  of  the  pelvic 
outlet,  with  the  cervix  somewhat  elongated  and  situated  in  the  long  axis 
of  the  vagina.  (See  Fig.  23.) 

Acquired  anteflexion  may  be  simply  an  exaggeration  of  the  normal 
flexure,  due  either  to  increased  weight  of  the  corpus  from  the  presence 


Fig.  24. 


of  the  uterine  fibroid  near  the.  fundus  or  to  unequal  growth  of  the  uterine 
walls  or  to  unequal  involution.  A very  frequent  cause  of  anteflexion  is 
thickening  of  the  posterior  wall  of  the  uterus  from  the  products  of 
inflammation,  and  a corresponding  atrophy  of  the  anterior  wall  from 
prolonged  pressure  at  the  angle  of  flexure.  Post-uterine  cellulitis  and 
peritonitis  involving  the  utero-sacral  ligaments  is  a frequent  and  dis- 
couraging complication.  Sometimes  the  inflamed  ligaments  contract  and 
drag  the  anteflexed  uterus  upward  and  backward,  where  it  may  be  per- 
manently fixed  by  peritoneal  adhesions.  (See  Fig.  24.) 

A constriction  of  the  uterine  canal  at  the  point  of  flexure  may,  by 
confining  the  secretions  above,  produce  inflammation  in  the  body  of  the 
uterus,  Fallopian  tubes,  and  ovaries  analogous  to  the  cystitis,  ureteritis, 
pyelitis,  and  nephritis  which  follow  stricture  of  the  male  urethra.  The 

Vol.  IV.— 12 


178 


DISPLACEMENTS  OF  THE  UTERUS. 


peri-uterine  inflammations,  having  the  relation  either  of  cause  or  effect 
of  the  flexure,  often  bind  the  pelvic  organs  together  in  a mass  of  exu  • 
date,  with  resulting  failure  of  nutrition,  nerve-irritation,  and  con- 
stant  pain,  which  sometimes  render  the  patient’s  life  miserable  and 
useless. 

Symptoms  and  Course. — The  numerous  symptoms  due  to  the  inflam- 
matory and  other  complications  should  not  be  confounded  with  those  of 
the  displacement.  The  symptoms  of  anteflexion  are  polyuria  and  dysuria, 
dysmenorrhoea  and  sterility. 

The  vesical  symptoms  are  produced  either  by  the  rigidity  of  the  uterine 
tissue  at  the  angle  of  flexure,  which  prevents  the  body  from  rising  out 
of  the  way  of  the  filling  bladder,  or  by  the  inflammatory  shortening  of 
the  utero-sacral  ligaments,  which,  by  drawing  the  uterus  upward  and 
backward,  put  the  vesico-vaginal  wall  on  the  stretch,  thereby  causing 
traction  upon  the  neck  of  the  bladder. 

The  dysmenorrhoea  may  depend  upon  the  presence  of  constriction  of 
the  uterine  canal  at  the  angle  of  flexure.  This  causes  the  blood  to 
accumulate  and  to  coagulate  in  the  body  of  the  uterus,  from  which  it  is 
expelled  at  intervals  by  uterine  contractions  simulating  labor-pains.  The 
pain  when  due  to  this  cause  is  therefore  always  very  severe  just  before 
the  passage  of  a clot.  Furthermore,  the  dysmenorrhoea  may  be  caused 
by  obstruction  in  the  veins  at  the  angle  of  flexure,  which  causes  intense 
venous  congestion  of  the  entire  body  of  the  uterus ; pain  is  then  due  to 
the  pressure  of  the  swollen  vessels  upon  the  nerve-filaments  and  to  a con- 
sequent irritable  condition  of  the  muscular  tissue  of  the  uterus.  Some- 
times upon  the  establishment  of  the  flow  the  uterine  canal  becomes 
temporarily  straightened  ; this  removes  the  cause  of  the  vascular  obstruc- 
tion, and  together  with  the  flow  gives  relief. 

Sterility  is  very  commonly  associated  with  anteflexion.  The  fact  that 
dilatation  and  incision  of  the  constricted  canal  have  frequently  been  fol- 
lowed by  conception  has  been  accepted  as  proof  that  the  sterility  is  due  to 
the  constrictive  obstruction.  This  mechanical  theory  is  questioned  by 
many,  who  say  that  the  dilatation  cures  sterility  by  straightening  the 
uterus  and  thereby  removing  the  venous  obstruction  and  the  consequent 
congestion. 

Diagnosis. — The  educated  touch  which  distinguishes  the  normal  ver- 
sion, flexion,  and  movements  of  the  uterus  will  appreciate  the  anatomical 
differences  between  pathological  and  normal  anteflexion.  The  degree  of 
flexure,  the  mobility  or  rigidity,  and  the  size,  shape,  location,  and  con- 
sistency of  the  uterus  may  be  ascertained  by  conjoined  manipulation. 
The  presence  of  post-uterine  cellulitis  is  recognized  by  the  pain  caused 
in  dragging  the  uterus  slightly  forward  and  by  increased  thickness  and 
tenderness  in  the  region  of  the  utero-sacral  ligaments,  which  may  be  felt 
by  vaginal  or  rectal  touch.  Anteflexion  is  distinguished  from  a fibroid 
in  the  anterior  wall  of  the  uterus  by  the  probe.  When  the  diagnosis  of 
anteflexion  is  obscured  by  the  presence  of  cellulitis,  it  is  usually  better  to 
wait  for  absorption  of  the  exudate  than  to  subject  the  patient  to  needless 
danger  from  the  probe.  Should  it  be  necessary  to  pass  the  probe,  the 
danger  is  decreased  by  gentle  manipulation,  which  is  facilitated  by  Sims’s 
speculum  and  the  latero-prone  position.  The  common  error  of  mistaking 
the  normal  version  and  flexion  of  a prolapsed  uterus  for  pathological 


PATHOLOGICAL  ANTEFLEXION. 


179 


version  and  flexion  has  been  exposed  in  a previous  paragraph.  (See 
Etiology  and  Clinical  History  of  Descent.) 

Treatment. — If  complicating  cellulitis  or  peritonitis  exist,  in  the 
relation  of  either  cause  or  effect  to  the  flexure,  its  removal  becomes  the 
prime  indication,  because  unless  removed  it  is  a positive  contraindica- 
tion to  the  more  direct  treatment  of  the  malposition  itself.  Chronic 
metritis,  hyperplasia,  hypertrophy,  and  irremovable  tumors  sometimes 
render  cure  impossible.  Improvement  of  the  general  health,  treatment 
of  complications,  and  palliation  then  become  the  only  resources. 

The  direct  treatment  of  pathological  anteflexion  has  for  its  object  the 
straightening  of  the  uterine  canal,  which  is  usually  accomplished  either 
by  division  of  the  cervix  or  by  dilatation.  But  before  considering  the 
treatment  more  specifically,  it  should  be  remembered  that  surgical  treat- 
ment of  anteflexion  in  cases  of  dysmenorrhoea  and  sterility  is  only  justi- 
fiable when  the  anteflexion  is  pathological.  To  say  that  most  women 
who  suffer  from  dysmenorrhoea  and  sterility  have  anteflexion  is  only 
saying  that  in  the  majority  of  such  cases  the  uterus  is  in  its  normal 
position. 

The  Marion-Sims  operation  of  dividing  the  cervix  is  open  to  two 
objections : first,  its  results  are  apt  to  be  only  temporary,  in  consequence 
of  rapid  contraction  upon  healing  of  the  wound;  second,  it  has  frequently 
been  followed  by  death.  Dilatation  by  means  of  tents  is  also  transient 
in  its  results,  and  dangerous  to  life.  Both  Sims’s  operation  and  dilatation 
by  tents  have  given  frequent  and  serious  warnings  in  the  shape  of  pelvic 
inflammations,  which,  if  not  destructive  to  life,  have  been  almost  as  dis- 
astrous in  their  influence  upon  health. 

The  following,  with  some  modifiations,  is  an  abstract  of  a valuable 
contribution1  by  Goodell  of  Philadelphia,  in  which  he  gives  positive 
endorsement  to  rapid  dilatation  as  proposed  by  Ellinger  and  others.  The 
instruments  recommended  are  two  Ellinger  dilators,  which  are  preferred 
on  account  of  the  parallel  action  of  their  blades.  The  dilatation  is  com- 
menced with  the  smaller  instrument  and  completed  with  the  larger,  which 
has  powerful  blades  that  do  not  spring  or  feather.  The  light  instrument 
needs  only  a ratchet  in  the  handle,  but  the  stronger  one  has  a screw 
which  forces  the  handles  together  and  the  blades  apart.  To  prevent 
injury  to  the  fundus  when  the  instrument  is  open,  the  length  of  the 
blades  is  limited  to  two  inches.  The  larger  instrument  has  a dilating 
power  of  one  and  a half  inches,  and  has  a graduated  arc  in  the  handles 
which  indicates  the  divergence  of  the  blades.  Goodell’s  modification  of 
Elliuger’s  dilators  is  provided  with  serrated  blades,  to  prevent  them 
from  slipping  out  of  the  canal  during  the  process  of  dilatation. 

For  dysmenorrhoea  or  sterility  due  to  flexion  or  stenosis  the  method  of 
operation  is  as  follows  : A suppository  containing  a grain  of  the  aqueous 
extract  of  opium  is  introduced  into  the  rectum,  the  patient  etherized,  and 
the  uterus  exposed  by  Sims’s  speculum.  The  cervix  is  held  by  a tenac- 
ulum, and  the  smaller  dilator  is  introduced  as  far  as  it  will  go.  Upon 
gently  stretching  open  that  portion  of  the  uterine  canal  which  it  occupies, 
the  stricture  above  so  yields  that  when  the  blades  are  closed  they  will 
pass  higher.  By  repeating  this  manoeuvre  a cervical  canal  is  tunnelled 
out  which  before  would  not  admit  the  finest  probe.  Should  the  os 
1 American  Journal  of  Obstetrics , 1884,  p.  1179. 


180 


DISPLACEMENTS  OF  THE  UTERUS. 


externum  or  cervical  canal  be  too  small  to  admit  the  instrument,  a pair 
of  pointed  scissors  may  be  substituted,  and  by  the  same  opening  and 
closing  motions  the  canal  may  be  prepared  for  the  introduction  of  the 
smaller  dilator.  As  soon  as  the  cavity  of  the  uterus  has  been  entered 
the  handles  are  brought  together.  This  dilator  is  then  withdrawn,  the 
larger  one  introduced,  and  its  handles  slowly  screwed  together.  If  the 
flexure  be  very  marked,  the  larger  instrument  after  being  withdrawn 
should  be  introduced  with  its  curve  in  the  opposite  direction  to  that  of 
the  flexure,  and  the  final  dilatation  made  with  the  dilator  in  this  position. 
But  in  reversing  the  curve  the  operator  should  take  care  not  to  rotate 
the  organ  upon  its  own  axis,  and  not  to  mistake  a twist  thus  made  for  a 
reversal  of  the  flexure;  the  ether  is  then  withheld,  and  the  instrument 
allowed  to  remain  in  place  until  the  patient  begins  to  flinch,  when  it 
is  removed.  The  best  time  for  the  dilatation  is  midway  between  the 
monthly  periods.  In  the  majority  of  cases  the  dilatation  should  be 
carried  to  about  one  and  a quarter  inches.  The  infantile  uterus  which 
has  failed  to  develop  at  puberty  has  thin,  unyielding  walls,  and  should 
therefore  not  be  dilated  more  than  three-fourths  of  an  inch  or  an  inch. 
I n using  the  larger  instrument  it  is  usually  necessary  to  have  the  assistant 
make  decided  counter-traction  with  the  vulsella  forceps  to  prevent  the 
blades  of  the  dilator  from  slipping  out.  The  cervix  is  sometimes  lace- 
rated, but  not  sufficiently  to  produce  unpleasant  results. 

GoodelPs  statistics  include  one  hundred  and  fifty  operations  of  full 
dilatation  under  ether,'  with  no  fatal  result  and  without  serious  inflam- 
matory disturbance.  As  precautions  against  cellulitis,  peritonitis,  and 
metritis  the  patient  should  be  fortified  for  the  operation  with  moderate 
doses  of  opium  and  full  doses  of  quinine,  and  for  two  or  three  days  after 
the  dilatation  this  should  be  continued  and  supplemented  by  the  applica- 
tion of  an  ice-bladder  over  the  abdomen. 

After  forcible  dilatation  under  ether  the  cervical  canal  rarely  returns 
to  its  previously  angular  or  contracted  condition.  The  cervix  shortens 
and  widens,  and  the  plasma  thrown  out  thickens  and  stiffens  the  uterine 
walls.  In  a small  minority  of  cases  the  operation  must  be  repeated. 
Dysmenorrhoea  or  sterility,  if  dependent  solely  upon  the  flexure,  is  cured 
by  the  dilatation.  The  comparative  safety  of  forcible  dilatation  in  the 
hands  of  a skilful  and  experienced  gynecologist  may  be  contrasted  with 
its  great  danger  when  undertaken  by  an  operator  unacquainted  with  the 
special  requirements- of  uterine  surgery.  Peri-uterine  inflammation  is  a 
positive  contraindication  to  the  operation. 

Post-uterine  inflammation,  which  has  drawn  the  anteflexed  or  ante- 
verted  uterus  upward  and  backward  by  the  contraction  of  the  utero- 
sacral  ligaments,  often  produces  traction  upon  the  vesico- vaginal  wall 
and  neck  of  the  bladder,  with  a constant  desire  to  micturate.  For  the 
relief  of  this  intractable  symptom,  which  sometimes  goes  on  to  cystitis, 
Emmet  has  proposed  a most  satisfactory  remedy  known  as  his  button- 
hole operation  of  urethrotomy.1  He  makes  a longitudinal  opening  about 
five-eighths  of  an  inch  long  through  the  urethro-vaginal  wall,  between 
the  meatus  and  the  neck  of  the  bladder,  without  cutting  through  either. 
To  prevent  the  opening  from  healing  together,  the  margins  of  the  mucous 
membrane  of  the  urethra  are  united  with  fine  catgut  sutures  to  the  mar- 
1 Emmet’s  Principles  and  Practice  of  Gynecology , 3d  ed.,  pp.  275  and  761. 


PATHOLOGICAL  ANTEFLEXION. 


181 


gins  of  the  mucous  membrane  of  the  vagina.  According  to  Emmet,  the 
operation  relieves  irritation  due  to  traction  on  the  neck  of  the  bladder  by 
freeing  the  pelvic  fascia  at  the  fixed  point  where  it  converges  to  its  pubic 
attachment.  The  operation  is  equally  applicable  for  the  relief  of  this 
symptom  when  due  to  inflammation  in  any  other  part  of  the  pelvis.  The 
same  result  may  be  secured,  but  less  satisfactorily,  by  forcible  dilatation 
of  the  urethra. 

From  personal  experience  the  author  can  testify  to  the  gratifying  effects 
of  this  operation.  Vesical  irritation  caused  by  post-uterine  inflammation 
and  consequent  contraction  of  the  utero-sacral  ligaments  is  often  wrongly 
attributed  to  the  mechanical  pressure  of  the  anteflexed  fundus  uteri  upon 
the  bladder,  which  is  manifestly  impossible,  if  the  contracted  utero-sacral 
supports  hold  the  entire  uterus  back  away  from  the  bladder. 

The  various  anteflexion  and  anteversion  pessaries  which  have  been 
devised  for  the  purpose  of  propping  up  the  corpus  are  almost  useless. 
Their  false  reputation  depends  upon  the  relief  which  they  frequently  give 
to  complicating  prolapse,  the  symptoms  of  which  have  been  wrongly 
attributed  to  anteflexion  or  anteversion.  The  same  pessaries  therefore 
may  be  applied  as  in  descent.  (See  Etiology  and  Clinical  History  of 
Descent.)  Intra-uterine  stem  pessaries  designed  to  straighten  the  flexed 
uterus  are  sometimes  effective,  and  always  dangerous. 


